
Class. 
Book 



COPYRIGHT DEPOSIT 




Case of Xanthelasma. 



THE 



READY REFERENCE HANDBOOK 



Diseases of the Skin. 



7 

GEORGE THOMAS JACKSON, M.D. (Col.), 

PROFESSOR OF DERMATOLOGY IN THE WOMAN'S MEDICAL COLLEGE OF THE >TW YORK IN- 
FIRMARY AND IN THE MEDICAL DEPARTMENT OF THE UNIVERSITY OF VERMONT ; CHIEF 
OF CLINIC AND INSTRUCTOR IN DERMATOLOGY, COLLEGE OF PHYSICIANS AND SUR- 
GEONS, NEW YORK ; CONSULTING DERMATOLOGIST TO THE PRESBYTERIAN 
HOSPITAL, NEW YORK, AND TO THE NEW YORK INFIRMARY FOR 
WOMEN AND CHILDREN ; MEMBER OF THE AMERICAN DER- 
MATOLOGICAL ASSOCIATION AND OF THE NEW YORK 
DERMATOLOGICAL SOCIETY. 



WITH SEVENTY-FIVE ILLUSTRATIONS. 



THIRD EDITION, BE VISED AND ENLARGED. 




LEA BEOTHEES & CO., 

NEW YORK AND PHILADELPHIA. 
1899. 









26774 



Entered according to the Act of Congress, in the year 1899, by 

LEA BKOTHERS & CO., 
In the Office of the Librarian of Congress. All rights reserved. 



TWO OOP1ES RECf.SVED. 



3- 1899 






\V,U©t? 






PUBLISHERS' NOTE TO THIRD EDITION. 

The brief period which has sufficed to exhaust the 
second edition of this work is a gratifying indication of 
the continued favor with which it is regarded by students 
id practitioners alike. It has been revised to represent 
J dermatological advances made in the interval, and en- 
tirely new sections will be found on Bulpiss, Bunion, 
Dermatitis from Roentgen Rays, Blastomycetic dermatitis, 
Ecphyma globulus, Lupus pernio, Pityriasis alba atrophi- 
cans, and Idiopathic multiple pigmented sarcoma. Six 
new illustrations have been added. The general plan of 
the book, outlined in the annexed Preface to the First 
Edition, remains unchanged, as it has proved its value. 

February, 1899. 



PREFACE TO SECOND EDITION. 



In the preparation of the second edition of this book 
the first edition has been entirely revised so as to bring 
the matter down to date, and new sections have been added 
upon Acromegaly, Actinomycosis, Angioma serpiginosum, 
Baelzer's disease, Cheilitis glandularis, Clavus syphiliti- 
cus, Dermatitis repens, Multiple benign cystic epitheli- 
oma, Erythema induratum, Erythema elevatum diutinum, 
Feigned Eruptions, Hyclroa vacciniforme or H. puer- 
orum, Osteosis cutis, Parakeratosis scutalaris et variegata 
and Porokeratosis. Nineteen new illustrations have been 
inserted, which it is hoped will add to the value of the 
book. The text has likewise been considerably increased. 

I would again express my gratitude to my friend Pro- 
fessor George Henry Fox for his kindness in placing at 
my disposal a number of pictures from his admirable col- 
lection of photographs, conspicuous for beauty and 
clearness. 

I can ask nothing better for this edition than the 
kindly acceptance accorded to its predecessor, and I ven- 
ture to express the hope that it will prove useful to all 
those interested in the treatment of skin diseases. 



14 East Thirty-first Street, 

New York, June, 1896. 



PREFACE TO FIRST EDITION. 



The following pages are intended to present the art of 
dermatology as it now exists. Xo attempt has been made 
to discnss debatable questions. Hence pathology and eti- 
ology do not receive as full consideration as symptoma- 
tology, diagnosis, and treatment. 

The alphabetical arrangement of the different diseases 
has been adopted for convenience of ready reference. It 
is hoped that the large number of titles from foreign lan- 
guages will prove as acceptable as it is novel, and that the 
pronunciations of the various names will be helpful. I 
would impress upon the reader the fact that in the pre- 
scriptions given no attempt has been made to translate 
grains, drachms, and ounces into their precise equivalents 
in grammes, but simply to preserve the relative percent- 
ages of the ingredients in the old formulae and express 
them in decimals. The decimals may be regarded as 
either grammes or parts. 

It gives me the greatest pleasure to acknowledge in 
this place and always my great obligations to my friends, 
Drs. George Henry Fox, Edward Bennett Bronson, 
and Bobert William Taylor. To the first two I owe a 
great deal of whatever knowledge of dermatology I may 
possess, and from all of them I have received many of 
those kindly courtesies that make a professional life worth 
living. 



Viu PREFACE TO FIRST EDITION. 

To Dr. F. P. Foster I would return most grateful 
thanks for his kind permission to use the system of pro- 
nunciation from his admirable Illustrated JEncyclopcedic 
Medical Dictionary, and for his courtesy in providing me 
with the pronunciation of many names in advance of their 
appearance in the same. 

I would also acknowledge my indebtedness to Dr. A. 
Rupp for special contributions upon eczema and furuncles 
of the ear, and to all those workers in dermatology from 
whose writings I have drawn freely so as to make this 
little book a presentation of modern dermatology. The 
admirable text-book of Dr. H. R. Crocker, of London, 
has been specially consulted by me, and has guided me 
through many a difficulty. 

Messrs. William Wood & Co. and D. Appleton & Co. 
have most courteously permitted me to make use of some 
papers of mine published in The Medical Record, The 
New York Medical Journal, and The Journal of Cutaneous 
and Genito- Urinary Diseases during the past years. 

14 East Thirty-First Street, 

New York, August, 1892. 



DISEASES OF THE SKIN. 



PART I. 
GENERAL CONSIDERATIONS. 

Anatomy and Physiology of the Skin. 

Before we enter upon the consideration of the separate 
diseases of the skin it will be well for us to refresh our 
memory as to its anatomy. It is not my desire to give a 
complete and exhaustive chapter on this subject, but to 
draw attention to those properties of the cutaneous envel- 
ope that are of practical importance to us. For a more 
extended consideration of this subject the student is re- 
ferred to Unna's article in Ziemssen's Eneyclopcedia 1 and 
Part I. of Duhring's Cutaneous Medicine. 2 

The skin is made up of three distinct layers, namely : 
1, the epidermis ; 2, the derma, also named the cutis vera, 
or corium ; and, 3, the subcutaneous connective tissue. 
The appendages of the skin are the hair and the nails, the 
sebaceous and the sweat glands. This complicated struc- 
ture is supplied with blood vessels, lymphatics and nerves. 

Epidermis. The epidermis is composed of four layers, 

called strata, namely: 1, the stratum corneum ; 2, the 

stratum lucidum ; 3, the stratum granulosum ; and, 4, the 

stratum mucosum. Of these strata, the two that most 

concern us are the first and the last — that is, the stratum 

corneum and the stratum mucosum. The other layers of 

1 Handbueh der Hautkrankheiten, Bd. xiv. Ziemssen's Encyclopaedia. 
2 Cutaneous Medicine. Phila., 1895. 

2 



18 



GENERAL CONSIDERATIONS. 



the skin may, for our present purpose, be regarded as 
simply transition-layers through which an epithelial cell 
passes on its developmental way to become a fully formed 



Fig. 1. 




Vertical section through, the skin. (After Heitzmann.) Diagrammatic. 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 19 

and rightly compacted corneous cell. Each of the four 
strata of the epidermis is divided again into layers, but 
these are of no practical importance. The thickness of 
the epidermis varies greatly, being thickest and most com- 
pact where it is subjected to the most pressure of inter- 
mittent character, as on the palms and soles. 

The stratum corneum consists of a series of superimposed 
layers of flattened, elongated cells that increase in flatness 
from below upward. The upper layers are called scales. 
The cells of each layer are united to each other so much 
closer than the layer itself is united to those above and 
below it that when an effusion takes place into the stratum 
corneum a layer of cells in the affected area is raised and 
the fluid is found between two layers. The lamellated 
scaling met with in certain scaly diseases, such as der- 
matitis exfoliativa, in which great plates of scales are 
readily removable, is likewise due to this close relation 
between the cells of each layer. This stratum is largely 
a protective one, its compactness affording a fair degree 
of resistance to injury of the underlying, more succulent 
layers of the epidermis. 

The stratum mucosum is the deepest layer of the epider- 
mis, and is seated upon the papillary layer of the corium. 
It is composed of several layers of cells, but may be consid- 
ered as consisting of two chief layers, namely, the columnar 
epithelium and the prickle cells. The columnar epithelial 
cells are arranged perpendicularly to the papilla? of the 
corium, while the prickle cells, which are polygonal in 
shape with spherical nuclei and with little filaments run- 
ning out from their sides toward the neighboring cells, are 
arranged in strata over them. As the stratum granulosum, 
which lies above the stratum mucosum, is approached, the 
prickle cells become flatter, and finally lie with their long 
axis parallel to the general surface. The "granules" 
contain eleidin (Ranvier) and keratohyalin (Waldeyer), 
the former being a solid and the latter a fluid substance. 
The stratum mucosum, also called the rete Malpighii, is 
the most important stratum of the epidermis, and the seat 



20 GENERAL CONSIDERATIONS. 

of that most common of all skin diseases, eczema. From 
its lower part it sends down projections between the 
papillae of the corium, which are called inter-papillary' 
projections. Most of the pigment of the skin is situated 
in the lower part of the stratum mucosnm. As the upper 
part is approached, less and less pigment is found. The 
pigment itself is in the form of granules and of diffused 
coloring-matter. According to Unna, the pigment is 
found even in the upper part of this layer, while in path- 
ological conditions it may be located in the corium. In 
the so-called colored races pigment is always found in the 
corium, and even the horny layer is stained. Negro 
babies at birth are but little darker than are white babies, 
but they become so. 

From this arrangement of the cells of the epidermis it 
will be seen that nutrient fluids can readily w r ork upward 
from below by means of the little channels formed by the 
interlacing of the filaments running between the cells. 

The epidermis has no blood vessels. It receives its nu- 
trition entirely from the corium. Though there are no 
true lymphatics in the epidermis, there are abundant 
lymph spaces between the cells that take their place. 
Nerves of the non-medullated variety have been traced 
between the cells of the epidermis, and have been de- 
scribed by some histologists as entering into the cells to 
end at the nucleus, though not to enter it. The final dis- 
tribution of the nerves in the epidermis is not yet fully 
determined. 

Corium. The corium is composed of white fibrous and 
yellow connective tissue, disposed in horizontal bundles 
above and in oblique bundles below. It is a very dense 
and tough tissue, and is pierced in all directions to allow 
of the passage of blood vessels, lymphatics, sweat ducts 
and nerves, and affords lodgement for the hair follicles 
and sebaceous glands. It contains a considerable amount 
of elastic fibers. The upper part has been named the 
pars papillaris, and the lower part the pars reticularis corii. 
From its upper part it sends off a vast number of projec- 



ANATOMY AND PHYSIOLOGY OF TEE SKIN. 21 

tions called papillae. These vary in length, being longest 
and most marked on the ends of the fingers and toes. 
The epidermis follows these projections and dips down 
between them. They are readily seen as parallel mark- 
ings on the ends of the fingers. Over most of the body 
surface the papillae are but slightly raised, and merely 
give a wavy appearance to the upper edge of the corium 
when viewed under the microscope. A fine basement- 
membrane separates the corium from the epidermis. This 
is regarded by some as a cement-substance. As we reach 
the lower part of the corium the bundles of fibers are less 
closely crowded together, and becoming successively looser 
gradually pass over into the 

Subcutaneous connective tissue. This is a loose connec- 
tive tissue with large and small spaces in it, which are 
filled with the adipose tissue. This consists of fat-cells 
collected into lobulated masses that in some cases have 
about them a connective-tissue sheath. Each lobule is 
supplied with an afferent artery, a capillary plexus about 
it, and efferent veins. This part of the skin is called the 
panniculus adiposus, and is found everywhere except in 
the skin of the penis, scrotum, labia minora, eyelids, pinna, 
and beneath the nails. It contributes to the roundness 
and beauty of the body, besides acting as a storehouse for 
fuel against such times as the body cannot gain its proper 
nutriment from food, as in fevers. It also gives lodge- 
ment to the coil or sweat glands, and aids in protecting 
the underlying parts from injury. The lower end of the 
deep hair follicles are also in this part of the skin. The 
subcutaneous tissue merges into the underlying fasciae of 
the muscles and the periosteum of the bones. Under the 
name of cplumnce adiposes J. C. Warren has described cer- 
tain prolongations of fatty tissue running up to the bases 
of the hair follicles. They are important in relation to 
the pathology of carbuncle. 

Blood vessels. The arteries which supply the skin 
come up from below to form a horizontal plexus in the 
subcutaneous tissue from which the, vessels proceed per- 



22 GENERAL CONSIDERATIONS. 

pendicularly through the corium to form a second hori- 
zontal plexus just below the papillae. From the lower 
plexus small branches pass to the fat-cells, sweat glands, 
and, according to Unna, to the hair papillae. From the 
upper plexus branches are given oif which enter the 
papillae of the skin. There are also branches to the hair 
follicles, sebaceous glands, and the tissue of the corium 
itself. Papillae that give lodgement to a tactile corpuscle 
have no arterial twig. The veins follow the same course 
as the arteries, but, of course, in the opposite direction. 

Lymphatics. Lymph vessels are large in the subcu- 
taneous tissue, smaller in the upper part of the corium, 
and form plexuses. " Juice-spaces," filled with lymph, 
are found abundantly in the epidermis and papillae, about 
the glands of the skin, and around the muscles of the skin 
and the connective-tissue bundles and fat-lobules. 

Nerves. The skin is provided with both medullated 
and non-medullated nerve-fibers and motor and vasomotor 
nerves. We have already learned that non-medullated 
nerve-fibers have been traced between the cells of the 
epidermis, some terminating at, if not in, the nuclei of 
the cells. It may be roughly stated that the nerves fol- 
low pretty much the same arrangement as the blood ves- 
sels, forming a sort of plexus beneath the papillae and then 
giving off branches to the vessels, to the tactile corpuscles, 
to the papillae, the hair follicles, the sebaceous and sweat 
glands, and the epidermis. 

The tactile corpuscles (corpuscles of Meissner) are located 
in the papillae. They are oval or round bodies, and their 
long axis runs longitudinally. Not more than one papilla 
in four is supplied with one of these corpuscles, even 
where they are most abundant — at the end of the index 
finger. They are composed, according to Unna, of 
large, flat connective-tissue cells, which are placed one 
above the other like money-rolls, and take up between 
them the terminal branches of the medullated nerves, 
which on entering the bodies lose their medulla and 
finally end between the cells. The transversely striped 



ANATOMY AND PHYSIOLOGY OF THE SKIN. 23 

appearance presented by the corpuscles is due to the swol- 
len lateral edges of the cells and the band-like nerve- 
fibers that here and there appear upon the surface. 

The corpuscles of Krause are located in the sensory 
mucous membranes. They are rounded in shape and 
bear a close resemblance to the Pacinian corpuscles in 
structure. 

The Pacinian corpuscles are located in the subcutaneous 
tissues, and also in connection with the sensitive nerves. 
They are oval in form, visible to the naked eye, and con- 
sist in a colossal swelling-out of the sheath of Schwann, 
forming a thick connective-tissue capsule surrounding a 
much smaller cylindrical cavity filled with granular, 
faintly filamentous cellular substance through the axis of 
which passes a sensitive nerve. As the latter enters the 
corpuscle it loses its medulla, and either terminates in 
the corpuscle or passes through it to enter one or more 
corpuscles. These corpuscles are most abundant in the 
fingers and toes, and the palms and soles. They are sup- 
posed to enable us to appreciate pressure or traction. 

Hair. The hair is an epidermic structure which grows 
from a nipple-shaped projection, the hair papilla, situated 
at the bottom of a deep, slender pocket or sac-like depres- 
sion in the skin which is called the hair follicle. Com- 
mencing at the papilla it is bulb-shaped. This part is 
called the bulb and fits over the papilla like a cap. On 
leaving the papilla the body of the hair is first called the 
root, and then as it becomes narrower the shaft. The 
diameter of the shaft rapidly decreases until, leaving the 
skin, it terminates in the point. A fully formed hair is 
hollow, its central cavity being called the medullary canal 
and filled with the medulla. This is composed of a col- 
umn of cells arranged in layers, one layer being superim- 
posed on another. The main substance of the hair is 
called the cortex, and consists of long spindle-shaped 
epithelial cells flattened out into fine bands and running 
in the long axis of the hair. This part of the hair gives 
it substance and strength, and in itis placed the pigment 



24 



GENERAL CONSIDERATIONS. 



that determines the color of the hair. The outer layer of 
the hair is called the cuticle. It corresponds to the epi- 



Fig. 2. 




Hair in follicle. (After Kaposi.) 

a. Follicle mouth. 6. Neck. c. Arch of follicle, d. Outer, e. inner sheath of 
follicle, p. Hair papilla, m. Fat-cells, n. Erector pili muscle, ep. Epidermis. 
s. Mucous layer of epidermis, o. Skin papillae, t. Sebaceous glands. /. External, 
g. internal root sheath, h. Cortex of hair. k. Medullary canal. I. Hair root. 

dermis and consists of flattened, non-nucleated, fully 
cornified cells which cover the hair like scales and over- 
lap each other like shingles. 

The hair follicle is located for the most part in the 
corium, but in some very strong hairs it reaches down 
into the subcutaneous tissue. It is always, excepting at 



ANATOMY AND PHYSIOLOGY OF THE SKIN 25 

the dorsal edge of the eyelids, placed at an angle to the 
skin, and is a permanent structure that is not removed 
when the hair is plucked. It is composed of three layers, 
which are derived from the corium as it dips down to form 
the follicle. Between the follicle and the hair we have 
the root sheath, which is derived from the epidermis. It 
is composed of two layers, which are called the external 
and internal root sheaths. The whole arrangement of the 
hair and its sheath may be graphically conceived by re- 
garding the hair as a blunt needle pressed against the skin. 
The needle would form the hair, the epidermis would form 
the root sheath, and the corium would be to the outside of 
all and form the hair follicle. 

Hair is found on all parts of the body excepting the 
palms and soles, the terminal phalanges of the fingers and 
toes, the glans penis, prepuce, labia minora, and the ver- 
milion border of the lips. In form it is flattened or 
rounded, straight or curled. There are three main varieties 
of hair : 1 . Long, soft hair, as of the head and beard. 

2. Short, stiff hair, as of the eyebrows and lashes ; and, 

3. Lanugo, or soft, downy, colorless hair that is scattered 
all over the surface of the body where the other varieties 
are not. 

Nails. The nails, like the hair, are epidermic struc- 
tures. They are placed on the extensor surfaces of the 
terminal phalanges of the fingers and toes. Their prox- 
imal end is called the root, under which is the matrix, 
from which they grow. On the way to their distal end 
they pass over the nail bed. This is separated from the 
matrix by a more or less, convex and apparent line called 
the lunula. At their posterior and lateral margins they 
are imbedded in a fold of skin that is called the nail fold. 
At their distal extremity they are separated from the end 
of the finger or toe. They are formed by the matrix, but 
in passing over the bed they receive a certain amount of 
nourishment from it, and their cells become rapidly corni- 
fied. They are slightly curved from side to side, being 
convex above and concave below, .and are marked with 



26 GENERAL CONSIDERATIONS. 

fine lines. The flesh beneath the nail is the same as the 
skin in general, though without subcutaneous tissue. The 
nail takes the place of the corneous and granular layers 
of the skin. It has been estimated that it takes from 
108 to 161 days for a finger nail to grow from the lunula 
to the free edge, the rate of growth being more rapid in 
summer than in winter. It has been noted that in a case 
of fracture of a limb the nails of the fingers or toes may 
cease growing until the bone is well knit. 

Sebaceous Glands. (Fig. 1.) These glands are of 
the racemose variety, and are closely related to the hairs, 
from two to six being attached to each hair, emptying by 
their ducts into the upper third of the follicle. Each 
gland is composed of a number of acini that empty by a 
common duct. They are composed of a delicate, struc- 
tureless capsule, the membrana propria, which continues 
along the duct to merge into the hair follicles. This is 
lined with large, though short, cubical or cylindrical ep- 
ithelial cells arranged in one or two rows. These are 
continuous through the duct with the cylindrical cells of 
the outer root sheath of the hair and of the skin. The 
interior of the glands is filled with fatty secretion. 
Around the gland passes the external layer of the hair 
follicle. These glands occur also on the vermilion border 
of the lips, the labia minora, and the glans penis and pre- 
puce, though in these locations there are no hairs. 

The function of the sebaceous glands is to oil the hair 
and skin, thus rendering them soft and supple, and giv- 
ing lustre to the hair. This oily secretion is produced 
by the cells, which, as they reach the central part of the 
acini, undergo fatty degeneration. The glands are largest 
in the nose, cheeks, scrotum, mons veneris, labia, and 
about the anus. 

Sweat Glands. (Fig. 1.) The sweat glands are simple 
coil glands that are located in the lower part of the corium 
and in the subcutaneous tissue. Their ducts ascend through 
the corium in a straight or wavy line to the interpapillary 
spaces, where they enter the epidermis. The cells lining 



ANATOMY AND PHYSIOLOGY OF THE SKIN 27 

the coil are simple cubical epithelial cells. These are 
seated upon muscular fibers ; and a connective tissue, the 
membrana propria, comes outside of all. An abundant 
network of blood vessels surrounds each gland and sends 
off branches to its interior. The glands are also richly 
supplied with nerves. The duct is made up of pavement- 
epithelium upon the membrana propria. When the epi- 
dermis is reached the membrana propria is lost, and the 
further tract of the duct seems to be made by the sweat 
working its own channel up between the epidermic cells. 
The duct ends as a rounded aperture on the surface of the 
skin that is called a sweat pore. Unna teaches that the 
sweat produced by the coil glands is mixed with other 
elements while passing through the epidermis, so that the 
secretion that appears at the sweat pores is not the same 
as that which leaves the coils. He further teaches that 
the office of the coil glands is not to produce sweat, but to 
oil the skin. This theory still needs confirmation before it 
can be accepted as proven. His arguments have consid- 
erable weight, but space will not allow of their statement 
here. It has long been known that there was a certain 
amount of oil in the sweat. Sweat glands are most numer- 
ous in the palms and soles. Their diameter is from 0.3 to 
0.4 mm. The largest are in the axillae, where they have a 
diameter of 2 to 7 mm. and are very numerous. In the 
external meatus of the ear they secrete the so-called ear wax. 
Muscles. The skin is provided with muscles, both of 
the striated and unstriated variety. The striated muscles 
are found in the face and nose. The majority of the mus- 
cles of the skin are involuntary muscles. In the scrotum 
they run parallel with the raphe. On the penis and about 
the nipple their direction is circular. The arreetores pi- 
lar urn muscles are found all over the body, running in a 
more or less oblique direction from the bottom of several 
papillae down and around a sebaceous gland to be attached 
to the bottom of a hair follicle. By contracting they raise 
the hairs to a perpendicular position and aid in pressing 
out the contents of the sebaceous glands. 



28 GENERAL CONSIDERATIONS. 

Diagnosis. 

The Lesions of the Skin. A knowledge of the 
lesions of the skin is essential to the understanding of der- 
rnatological literature. It is well to acquire it as soon as 
possible, for, though after one has once become versed in 
dermatology, he probably will not stop to think whether 
a given disease is papular, vesicular, pustular, or not, but 
will name it from its physiognomy ; nevertheless, in doubt- 
ful cases the recognition of the most prominent lesion will 
sometimes aid in diagnosis. Furthermore, time will be 
saved and clearness gained by using the proper phrase- 
ology in describing a case. 

We speak of primary and secondary lesions of the skin. 
By the first of these terms we mean the form assumed by 
the efflorescence at its first appearance. By the second of 
these terms we mean the subsequent changes the primary 
lesion undergoes of itself, or as the result of extraneous 
causes acting upon it. In running its course, whether in- 
fluenced by treatment or not, almost every disease of the 
skin exhibits more than one lesion, and we can only speak 
of it as a macular, papular or other disease from its most 
prominent and characteristic lesion. 

The primary lesions of the skin are the macule, the 
papule, the tubercle, the vesicle, the pustule, the bulla, 
the wheal and the tumor. The secondary lesions of the 
skin are the crust, the scale, the excoriation, the fissure, 
the ulcer, and the cicatrix. These may be graphically 
represented, following PifTard. 1 

Primary Lesions. A macule is a spot or stain of the 
skin which is not raised above its surface. It may be of 
any size from a pin-point to the palm of the hand, or 
larger ; but these large-sized and diffused, non-elevated 
lesions are usually spoken of as patches. It is usually 
round, but may be of any shape. It may be white, red, 
brown, black, blue, pink, or yellow, according to its cause. 
It may be due to hyperemia, as in erythema simplex ; to 
Cutaneous Memoranda. Wood, N. Y., 1885. 



DIAGNOSIS. 29 

a change in the pigmentation of the skin, as in lentigo and 
chloasma, where there is increase of pigmentation, or in 
vitiligo, where there is decrease of pigmentation ; to a 
hemorrhage into the skin, as in purpura ; to a develop- 
ment of blood vessels in the skin, as in nsevus vascularis 
and telangiectasis ; to a parasitic growth in the skin, as in 
chromophytosis ; or to a change in the consistency of the 
skin, as in morpheea and xanthoma. 

Fig. 3. Fig. 4. 



LESIO>"S OF THE SKrX. 

Primary. Secondary. 



Macule 



Papule 



Tubercle 



Vesicle 




A 




Bulla 



Wheal 



Tumor 



Crust 



Scale 



Fissure 



Ulcer 



Cicatrix 



V V 



XXX 




The macule may be evanescent or permanent ; may re- 
main as a macule during its existence, or may give place 
to a papule, vesicle or pustule. It is the simplest of all 
the lesions of the skin, and is met with as a primary 
lesion of many of its diseases. 

The principal macular diseases are chloasma, chromo- 
phytosis, erythema simplex, lentigo, melasma, morphoea, 
nsevus simplex and spilus, purpura, scleroderma, vitiligo 
and xanthoma. 



30 GENERAL CONSIDERATIONS. 

A papule is a circumscribed, solid elevation of the skin. 
In size it varies from that of a pin-point to that of a split 
pea. It may be of different colors, but is usually some 
shade of red. It is soft or firm to the touch. In form 
it may be acuminated, rounded, flattened, umbilicated, or 
angular. It may be due to inflammation, as in eczema ; 
to a hypertrophy of normal structures, as in verruca ; to 
the heaping up of epidermic cells about a hair follicle, as 
in keratosis pilaris ; or to the retention of sebaceous mat- 
ter in a follicle, as in comedo and milium. 

The papule may remain as such throughout its course, 
and finally be absorbed ; or it may change into a vesicle 
or pustule ; or it may soften and break down. 

Papular diseases have received the name of lichenoid 
diseases, and at one time we had a goodly number of 
lichens. Most of these have now been placed under 
other headings, as it is recognized that they are but single 
manifestations of other diseases. Papular diseases are 
apt to be scaly and itchy. 

The principal papular diseases are : lichen tropicus, 
lichen ruber acuminatum and planus, lichen scrofulosorum, 
lichen pilaris or keratosis pilaris, lichen urticatus or pap- 
ular urticaria, acne, comedo, milium, prurigo, and psoria- 
sis. Like the macule, the papule is found in many dis- 
eases that cannot be classed as papular. 

A tubercle may be thought of as a large papule. Like 
it, it is a circumscribed solid elevation of the skin, usu- 
ally of a reddish color. Indeed, the difference between 
a papule and a tubercle is mainly arbitrary and for con- 
venience. Thus, we speak of a solid lesion up to the 
size of a split pea as a papule, while above that it is 
spoken of as a tubercle. Quite commonly, when a lesion 
is larger than a cherry it is spoken of as a node. Au- 
spitz l makes the distinction between a papule and tu- 
bercle on more scientific grounds, and regards a tubercle 
as a cell-infiltration into the corium. A tubercle is not 
only larger than a papule, but it extends deeper into the 
1 Ziemssen' s Handbuch der Hautkrankheiten. 



DIAGNOSIS. 31 

skin. In form and color a tubercle corresponds to a 
papule. 

Tubercles may be absorbed and disappear and leave no 
trace ; or they may break down and ulcerate and leave 
scars, as in syphilis ; or they may remain unchanged for 
an indefinite period, as in molluscum. 

The principal tubercular diseases are : carbuncle, epithe- 
lioma, keloid, lupus vulgaris, molluscum, rhinoscleroma, 
and xanthoma. Tubercles form a very prominent symp- 
tom in leprosy, syphilis, and erythema multiforme. Of 
course, tubercular used in this sense has nothing to do 
with true tuberculous processes. 

A vesicle is a circumscribed elevation of the epidermis 
that contains fluid, generally serous. In size it varies 
from a pinhead to a split pea. Its color is crystalline 
when only serum is present, more or less opaque and yel- 
lowish when the serum is mixed with pus, and of a red- 
dish hue when blood is effused into it. It may be pointed, 
rounded, flattened, or umbilicated. Vesicles are in most 
cases due to inflammation, as in eczema. They may be 
due to simple serous effusion, as in erythema ; or to the 
retention of sweat, as in sudamina. They have around 
them, in many cases, a red halo. As a rule, vesicles are 
superficial elevations of the epidermis, and readily rupture 
and pour out their contents upon the skin, forming a 
yellowish crust. They may be below the mucous layer 
of the skin. They may remain as vesicles, and dry up, 
their contents being absorbed ; or they may become 
changed into pustules. 

The principal vesicular diseases are : dermatitis venen- 
ata, dysidrosis, eczema, herpes, hidrocy stoma, impetigo 
contagiosa, sudamina, varicella, and zoster. 

A pustule is a circumscribed elevation of the epidermis 
containing pus. In size and shape it corresponds to the 
vesicle. Its color is yellow and opaque ; or brown or 
reddish if there is an admixture of blood with the pus. 
It either originates as a pustule or develops from a 
vesicle or papule. As a rule, pustules are inflammatory, 



32 GENERAL CONSIDERATIONS. 

and when they appear as a general eruption, as in syph- 
ilis, they indicate a strumous or broken-down condition. 
Around each pustule there is very commonly a well- 
marked inflammatory areola. 

Pustules are prone to break down and discharge their 
contents upon the skin, forming a greenish crust. If 
located deep in the skin they may leave scars. 

The principal pustular diseases are acne vulgaris, ec- 
thyma, furunculosis, impetigo, and sycosis. Eczema, 
syphilis and a feAV other dermatoses are often markedly 
pustular in character. 

A bulla may be considered as a large vesicle or pustule. 
It is of irregular oval shape or umbilicated. It may be as 
large as a split pea, or reach the size of a goose egg. It 
rises up from the skin with a slight areola or with none at 
all. It is either fully distended or flaccid, and does not 
rupture readily. It may be a bulla from the beginning, as 
we see in pemphigus; or it may be formed by the coalescence 
of two or more vesicles ; or it may form above an erythe- 
matous lesion, as hi erythema multiforme. Its contents 
are usually serous, but this may give place in time to pus. 

The only purely bullous disease is pemphigus, but bullae 
are met with in dermatitis, dermatitis herpetiformis, ery- 
sipelas, erythema multiforme, leprosy, and syphilis. 

A wheal is an evanescent round, oval, or elongated flat 
elevation of the skin, of a pinkish or white color, which is 
more or less firm to the touch. It is surrounded by a red 
halo. It may be as small as a pea or as large as the palm 
of the hand. Wheals appear suddenly and disappear with- 
in a few hours. They are due to a spasm of the capillaries 
and an effusion of serum into the meshes of the skin, the 
raised part being the site of the effused fluid, and the halo 
the congested vessels in the neighborhood. The disease 
in which wheals are met with is urticaria. They can also 
be produced by contact with the stinging-nettle, or by 
sharp traumatism on skins predisposed to urticaria. 

A tumor is a new growth in the skin which projects more 
or less above its surface and dips down into the subcutane- 



DIAGNOSIS. 33 

ous tissue. It may be pedunculated. Tumors vary greatly 
in size. Their color is often that of the surrounding skin, 
but they may be red. They may become ulcerated. It is 
rather a surgical than a dermatological lesion. Epitheli- 
oma, fibroma, and sarcoma are types of tumors. They are 
met with also in syphilis and scrofula. 

Secondary Lesions. The secondary lesions of the 
skin require a much less extended description. The main 
distinction to be retained in the student's mind is that be- 
tween a crust and a scale. This can be readily done if it 
is remembered that a crust is formed by the drying of 
some secretion or exudation upon the skin : while a scale 
is a dry, laminated mass of epidermis which has separated 
from the tissues below ; the product of imperfect or per- 
verted nutrition. Thus, in vesicular eczema when the 
exudation dries on the skin we have a yellowish crust ; 
while in squamous eczema we have thin scales, the horny 
layer of the skin not being perfectly produced. Crusts 
are light-yellow to dark-green or black in color, the lat- 
ter indicating an admixture of blood. Scales are whitish, 
grayish, yellowish or dirty yellow. 

Crusts are especially characteristic of. ecthyma, some 
forms of eczema, favus, impetigo, and seborrhcea. 

Scales are specially abundant in dermatitis exfoliativa, 
pityriasis simplex, pityriasis rubra pilaris, psoriasis, ich- 
thyosis and some of the lichens. 

Excoriations are familiar as scratch marks. They are 
superficial denudations of the skin. They are of value 
as a sign of itching, as scratching is their chief, though 
not sole, cause. They frequently are followed by pig- 
mentation, if the irritation causing the scratching is long- 
continued. They also occur as the natural result of some 
diseases, such as pemphigus, without the intervention of 
scratching. 

Fissures are cracks in the epidermis extending down to 

the corium. They are usually located in the folds of the 

skin, as over the joints. They occur in diseases attended 

by infiltration and thickening of the skin by which its 

3 



34 GENERAL CONSIDERATIONS. 

elasticity is interfered with, and are especially seen in 
eczema, psoriasis and syphilis. They often bleed, and 
sometimes are very painful. 

Ulcers are irregularly shaped and sized losses of sub- 
stance. They may be quite small, or of very large size. 
They may be shallow, deep, excavated, or scooped out. 
Their edges may be undermined, as in scrofula ; everted, 
as in epithelioma; or sharp-cut, " punched out," as in 
syphilis. Their secretion may be scanty or abundant. 
They result either from some previous lesion or from in- 
jury. They occur in carbuncle, chancre, chancroid, ec- 
thyma, varicose eczema, epithelioma, furuncle, lupus vul- 
garis, sarcoma, scrofula, syphilis, and sometimes after 
zoster, dermatitis and some pustular eruptions. They 
always heal with a cicatrix, leaving a scar. 

Cicatrices, or scars, represent the effort of Nature to heal 
a damage to the skin by means of connective tissue. They 
occur only when the papillary layer of the skin or the parts 
beneath are destroyed. They may be depressed, as in 
smallpox ; raised and puckered, as in lupus ; smooth and 
white, as in syphilis. While ulceration usually precedes 
them they occur independently of it, as in leprosy, sclero- 
derma, and atrophoderma. 

Other Elements of Diagnosis. Having mastered 
the lesions of the skin, we are now prepared to study the 
other elements of diagnosis. We must observe the loca- 
tion, distribution, and configuration of the eruption, and 
note its color, and whether or not it itches. When we 
have done all this, and have come to a probable conclusion 
as to the disease before us, then is the proper time to ask 
the patient a few questions as to his sensations and the 
duration of the attack. In a few cases of doubtful diag- 
nosis the microscope will aid us. 

Location. Upon the face we meet with acne, com- 
edo, chloasma, erythematous eczema, epithelioma, herpes 
febrilis, lupus vulgaris and erythematosus, milium, rosacea, 
sycosis, and xanthoma. 

An eruption occupying the middle third of the face, 



DIAGNOSIS. 35 

from above downward — forehead, nose and chin — is in all 
probability rosacea. 

An eruption occupying the bearded portion of the face, 
above a line drawn from the angle of the mouth to the 
angle of the jaw, is probably sycosis. Should it occupy 
the bearded portion of the face below that line it is prob- 
ably trichophytosis barbae. 

If a scaly patch is found in front of the ear it should 
put us on the lookout for psoriasis, which will often be 
found elsewhere on the body. This point may be useful 
in the diagnosis of a doubtful case. If a raw, or cracked 
or scaly place is found behind the ear it points to eczema. 

Upon the scalp we meet with alopecia, alopecia areata, 
eczema, favns, pediculosis capillitii, seborrhoea and tricho- 
phytosis. 

If we find a patch of pustular eczema upon the back of 
the head and about the nape of the neck the case is prob- 
ably one of pediculosis, and if we look for the nits we 
shall find them either at the site of the eruption or over 
the parietal region. 

The chest is the favorite location for chromophytosis and 
keloid. 

Upon the back we meet with acne, carbuncle and the 
scratch marks due to the irritation from pediculi. If we 
find long, parallel scratch marks over the shoulder blades 
it is quite good evidence of pediculi in the clothing. 

The extensor surfaces of the forearms and wrists are the 
favorite sites of erythema multiforme, while the flexor 
surfaces give lodgement to lichen planus and scabies. The 
posterior surface of the elbow is a common location for 
psoriasis, while on the soft skin of the bend of the elbow 
we find eczema. 

Upon the legs elephantiasis, erythema exudativum, 
purpura and ulcers are apt to occur. 

A general eruption is either one of the exanthematous 
fevers, dermatitis exfoliativa, eczema, erythema, ichthy- 
osis, lichen planus, lichen ruber acuminatus, pityriasis 
rubra pilaris, psoriasis, scabies, or syphilis. 



36 GENERAL CONSIDERATIONS. 

Of these, syphilis is most marked on the sides of the 
chest and abdomen, and upon the face along the margin 
of the hair. It may also be given as a general rule, 
to which there are many exceptions, that syphilis oc- 
cupies the flexor surfaces of the extremities and the ante- 
rior plane of the trunk, while psoriasis is found most 
markedly upon the extensor surfaces of the extremities 
and the posterior plane of the trunk. 

Configuration. Certain diseases assume certain con- 
figurations, which, if noted, will sometimes assist in 
diagnosis. Thus we have 

The circular outline and scalloped border of syphilis. 

The round and bald patch of trichophytosis and alopecia 
areata. 

The map-like border of psoriasis. 

The oval or egg-shaped lesions of erythema nodosum 
and the gumma of syphilis. 

The angular umbilicated papules of lichen planus. 

The annular arrangement in herpes iris and pityriasis 
rosea, and in some cases of ringworm, psoriasis, syphilis 
and seborrhoea corporis. 

The patches of grouped vesicles upon reddened bases 
located over the course of a cutaneous nerve in zoster. 

The Differential Diagnosis of Kinged Erup- 



tions. 



The eruptions that appear, either habitually or occa- 
sionally, in ring-shape are trichophytosis corporis, syph- 
ilis, psoriasis, erythema multiforme, seborrhoea sicca, pity- 
riasis maculata et circinata, and, rarely, favus of the 
body, in its so-called herpetic stage. These eruptions 
often bear so strong a resemblance to one another that it 
is hard for even experts to make a positive diagnosis. 
It is, therefore, small wonder that the physician who has 
not had much experience in skin diseases should some- 
times make an error in diagnosis. Happily, each one of 
1 American Medico-Surgical Bulletin. 



DIAGNOSIS. 37 

them does have certain so well-defined features that a 
sure diagnosis can be made in the great majority of cases. 
It is my desire to indicate the points in differential diag- 
nosis between them. 

Trichophytosis, or ringworm, may be taken as the type 
of ringed eruptions. It must be clearly understood at 
the outset what we mean by an annular or ringed erup- 
tion. It is one that has a well-defined raised border sur- 
rounding a patch of skin that is normal or nearly so, or 
in which active disease has ceased. A circular patch, 
such as is seen in alopecia areata, is not a ringed erup- 
tion, as it does not present a well-defined raised border, 
and the whole patch is equally affected. In ringworm 
we have a well-defined, slightly raised border composed 
either of vesicles, rarely seen, or pustules, or papules that 
are slightly scaly, or of small crusts, the remnants of the 
vesicles or pustules. Inside of this ring the skin may 
show no change, or be slightly scaly, the scaliness dimin- 
ishing toward the center. The eruption usually itches 
slightly. There may be only one patch, or several in dif- 
ferent stages of development. If there is any doubt 
about the diagnosis it will readily be cleared away by 
examining some of the scales under the microscope, when 
if it be trichophytosis the fungus will be found with ease. 

This form of ringed eruption differs from syphilis : in 
itching ; in having a narrow border made up of scales, 
vesicles, pustules, or crusts ; in its scaly center ; in being 
superficial, and in its microscopical characters. It differs 
from psoriasis : in its superficial character ; in its border 
not being covered with silvery scales ; in not being a gen- 
eral eruption ; in its parasite, and in not being of a pink- 
ish-red color. It differs from erythema : in not being a 
symmetrical eruption ; in its narrow border ; in its color, 
that cannot be made to disappear under pressure, and in 
having a fungus growth as its cause. It lacks the greasy 
character of seborrhoea sicca, and differs from the latter 
also in the presence of the trichophyton fungus. It differs 
from pityriasis rosea : in not being a general eruption ; in 



38 GENERAL CONSIDERATIONS. 

its center being slightly grayish, and not of the appearance 
of chamois leather, and in being parasitic. 

Syphilis at times shows itself in rings. These have one 
striking negative character, and that is that they do not 
itch or burn. All the other ringed eruptions either itch 
or burn to a greater or less degree. It has a well-marked, 
rather broad, slightly elevated border, which is infiltrated, 
raw-ham colored, and composed of either scaling papules 
or of nodules. The center of the ring may be normal, 
scaly, crnsted, superficially or deeply cicatrized, reddened 
or pigmented. Sometimes the nodules of the border may 
break down and ulcerate. Occurring on the palms or 
soles, the border may be hardly, if at all, elevated, but 
simply red and scaly. This is due to the thickness of the 
epidermis in these regions. It is quite characteristic of 
the annular syphilide that it is often an incomplete ring, 
the border being broken at some point. The diagnosis 
will be aided by finding other evidences of syphilis, which 
usually are to be found. This form of ringed eruption 
differs from ringworm in the way already indicated. As it 
is quite possible for a syphilitic subject to have any of the 
other ringed eruptions, a history of the case will sometimes 
be unreliable, if depended on for diagnosis. It is, there- 
fore, better to make the diagnosis solely on what we see. 
It is only in very doubtful cases that a history of the 
eruption is desirable to help us to decide aright, and then 
only after a careful weighing of the evidence. A ringed 
syphilide is most apt to be confounded with psoriasis, but 
it differs from it : in having a raw-ham, and not a pinkish- 
red, color ; in not itching ; in showing a red seam beyond 
the scales ; in the scales being less silvery, smaller and 
more abundant ; in the border formed of individual le- 
sions ; in not being so generally distributed over the body, 
and in not occurring in the characteristic sites of psori- 
asis — that is, on the elbows and knees. If the case were 
psoriasis there would surely be some characteristic patches 
to guide us. Erythema multiforme and syphilis are so 
unlike in every respect that it is hardly possible they 



DIAGNOSIS. 39 

could be confounded. Seborrhoea corporis is located on 
the chest and between the shoulder blades, and there will 
be found at the same time seborrhoea on the scalp. These 
are not characteristic of syphilis. Moreover, syphilis 
lacks the greasy feel of seborrhoea. The raw-ham color 
of the syphilide is never seen in seborrhoea. Pityriasis 
rosea is readily distinguished from syphilis by the occur- 
rence at the same time of both macules and rings, by its 
lighter color and by the chamois-leather look of the con- 
tents of the rings. The infiltrated border of the syphilide 
distinguishes it from all the other ringed eruptions. 

When psoriasis forms rings it does so by the clearing 
up of the centers of old patches, and there will be char- 
acteristic patches of psoriasis to guide us in diagnosis. 
The border of the ring is usually quite broad and slightly, 
if at all, thickened ; its color is the pinkish-red of psoria- 
sis, and the scales that cover it are large and silvery. 
The center of the ring is composed of normal skin, which 
may be a little red. The scaling will be seen to be com- 
mensurate with the redness. It is commonly itchy. 

The differential diagnosis from syphilis and ringworm 
has been given above. Like the syphilide, it bears no 
resemblance to erythema, except in its ring-shape. From 
seborrhoea it differs in not being greasy and in its silvery 
scales. At times the two diseases do bear a close resem- 
blance to each other, but even then it will usually be easy 
to find some typical lesions of one or the other disease to 
decide the matter. There is little likelihood of confound- 
ing psoriasis with pityriasis rosea, as the former is much 
less superficial than the latter, and its scales are large and 
silvery, and not small and adherent ; besides, it lacks the 
chamois-leather color, which is a marked feature of pityri- 
asis rosea. 

Erythema multiforme, or erythema exudativum, not in- 
frequently forms rings by the absorption of the centers of 
large tubercular lesions or patches. It is easy to recognize 
the lesion, as there will be other and characteristic erythe- 
matous lesions to guide us. The border of the ring is 



40 GENERAL CONSIDERATIONS. 

raised and its color is red, the redness, as in all erythe- 
matous lesions, being readily made to disappear on pres- 
sure, to return promptly when the pressure is removed. 
When the lesion has lasted for some time the color be- 
comes darker and cannot so readily be made to disappear, 
because now the coloring-matter of the blood remains be- 
hind in the tissues. The center of the ring is red or 
discolored on account of the partially absorbed exudate. 
Another form of ringed erythema is what is known as 
erythema, or herpes, iris, in which we have either a pur- 
plish spot surrounded by a raised whitish ring containing 
fluid, and outside of this a red areola ; or a vesicle in the 
center with a purplish zone about it, a raised whitish ring 
containing fluid, and a red areola outside of all ; or a 
central bulla with one or two rings of vesicles about it. 
This form of erythema is usually symmetrical, and occurs 
upon the extensor surfaces of the arms and legs and upon 
the backs of the hands and feet. It may occur as part of 
a general erythema multiforme or by itself. The ringed 
erythema is so peculiar in its features as to oifer little 
difficulty in differential diagnosis, and need not detain us 
further. 

Seborrhoea sicca, or seborrheal eczema, as it is now 
called, is the lichen annulatus of Wilson and the sebor- 
rhoea corporis of Duhring. It forms ring-shaped lesions 
on both the scalp and trunk. These are best and most 
often seen on the trunk, but may also be found on the 
limbs. Their favorite sites are the chest and the back 
between the shoulder blades. The rings are of large and 
small size, and at the same time there will be found fatty 
plates with more or less redness, the usual lesions of seb- 
orrhoea sicca. The border of the ring may be broad or 
narrow. If the former, then it will be formed of greasy 
crusts upon a reddened base ; if the latter, the border will 
be seen to be made up of a number of red points, the 
open mouths of the follicles of the skin ; or the border 
may be narrow and yet made up of fatty crusts. The 
skin in the neighborhood is commonly greasy, and the en- 



DIAGNOSIS. 41 

closed area of skin will look as if varnished, being glazed 
and yellow. 

The differential diagnosis from ringworm, syphilis and 
psoriasis has been given already. The greatest difficulty 
is often found in the diagnosis from pityriasis rosea, es- 
pecially when the ringed lesions are on the legs. The 
resemblance is then so great that it has led some to 
question if both the seborrhoea and the pityriasis are 
not identical. As a rule, the seborrheal lesion is more 
fatty and yellow, while that of pityriasis is more scaly, 
and the contained skin is more wrinkled and chamois- 
leather-looking. In typical cases there will be no diffi- 
culty in the diagnosis if the characteristics of both dis- 
eases are borne in mind. The presence of a seborrhoea 
on the scalp is corroborative evidence of the seborrheal 
nature of a doubtful eruption. 

Pityriasis rosea, or pityriasis maculata et circinata, not 
only shows rings, but also, as its name indicates, macules, 
and both forms of lesions are always present at the same 
time. It can be easily seen that the primary lesion is a 
pale-red papule, increasing in size, to become later a rosy- 
red lesion, which, after attaining a certain size, clears up 
in the center, so as to form a ring with a pale-red border 
and a yellow, old-parchment, or chamois-leather-like cen- 
ter. Both the borders and inclosed areas are slightly 
scaly. It is usually most pronounced on the chest and 
shoulders, but it may be a general eruption, though the 
hands, feet and face are rarely affected. Its differential 
diagnosis has been given under the previously described 
diseases. 

It is a property of all these eruptions that, if two or 
more of their rings appear near each other, they are very 
apt to run together and form figure-of-eight or gyrate 
lesions from the disappearance of the borders at the part 
where contact has taken place. 

The ring-shaped or herpetic form of ' favus is not com- 
monly seen. It occurs in favus of the body. It will 
then bear so strong a resemblance to ringworm that at 



42 GENERAL CONSIDERATIONS. 

first it is impossible to distinguish which it is ; but it is 
only necessary to wait a short time, when a well-marked 
favic cup will develop. 

Lichen planus papules, when they have crowded together 
into a patch, will form into rings at times by the absorp- 
tion of the central papules. The ring is rarely of large 
size ; its color is the peculiar violaceous color of lichen 
planus ; the center is depressed and the whole is scaly. 
As these rings are never seen apart from the simultaneous 
occurrence of characteristic flat, angular, smooth papules, 
with central umbilication, there is no possibility of con- 
fusing them with those of the other ringed eruptions. 

We occasionally see rings in lupus erythematosus and 
in epithelioma, but such occurrences are exceptional. 
When they do occur the other signs of the one or the 
other disease will be so much in evidence that there will 
be little danger of mistake in diagnosis. 

Lupus erythematosus has a peculiar red color ; its border 
is usually covered with closely adherent scales, and the 
ring will have a cicatricial center. At the same time 
there will be other patches present of typical lupus ery- 
thematosus. 

Epithelioma, even when it does form a ring, has that 
characteristic hard, raised, waxy border which we see in 
all epitheliomas of the skin, and that will be enough for 
diagnosis. 

Color. An eye for color is of some value in diagnosis. 
It is very difficult to convey by words a correct idea of 
the color of an eruption, but perhaps this list may prove 
helpful : 

Raw ham of syphilis. 

Brilliant red of erysipelas. 

Inflammatory red of eczema. 

Dark red of purpura. 

Bright red of psoriasis. 

Brown of pigmentary diseases. 

Sulphur-yellow of favus. 

Buff of xanthoma. 



DIAGNOSIS. 43 

Violaceous or dull red of licheu planus and lupus 

erythematosus. 
White of leucoderma. 

History. Having carefully noted all these objective 
symptoms, we have by this time pretty well made up our 
minds as to the diagnosis of the case. Now is the time 
to obtain the history of the case, either for the purpose of 
scientific study of its etiology and natural course, or for the 
purpose of clearing up some doubt as to our diagnosis. It 
is so easy to obtain a history of syphilis that were we influ- 
enced by the history we would be often misled. There is 
no reason why a patient with syphilis should not have any 
other skin disease. Moreover, most people do not pay 
much attention to the history of their diseases, and it 
would be difficult for them to give a correct account of 
themselves if they would. Of course, a clear history of 
the initial lesion of syphilis, or its presence, would clear 
up any doubt as to an erythematous rash. The history 
of a scaly disease recurring at frequent intervals upon the 
elbows and knees would go far to determine the existence 
of psoriasis. In urticaria we often have to rely upon the 
statement of the patient or attendant as to the appearance 
of the wheals, as their presence at some time is pathog- 
nomonic, and they are usually absent when we see the 
patient. In these and similar ways the history is useful, 
but it should be entirely subordinated to the study of the 
objective symptoms. 

Pruritus. It is important to know whether a disease 
itches or not. This we can discover by the presence or ab- 
sence of scratched papules or scratch marks. The itching 
eruptions are dermatitis herpetiformis, eczema, pediculosis, 
prurigo, pruritus cutaneous, scabies and urticaria. The 
symptom is also present in the lichens, psoriasis, sebor- 
rhea, and trichophytosis. It is markedly absent in 
syphilis, though an occasional case of syphilis will be 
encountered in which there is itching. 

Burxixg. The sensation of burning is one the exist- 
ence of which we must take upon the patient's statement. 



44 GENERAL CONSIDERATIONS. 

It is a prominent symptom in erythema. Very often a 
patient will say that his eruption itches, but if you watch 
him he will soon begin to rub his skin gently with the 
heel of his hand. This indicates that the sensation is one 
of burning and not of itching. In itching, the nails are 
used, or else the rubbing is vigorous. 

Pain. Another symptom for the establishment of which 
we have to rely upon the patient is that of pain. The 
vast majority of skin diseases, while they may cause more 
or less discomfort, are not painful ; but sharp neuralgic 
pain is a prominent symptom in epithelioma and zoster. 
The presence of pain of a shooting character will be one 
point in the differential diagnosis between lupus and epithe- 
lioma, and in favor of the latter. We also meet with 
pain in neuroma, dermatalgia and in some forms of leprosy. 

Microscope. The principal use of the microscope in 
the hands of the general practitioner is, as far as derma- 
tological diagnosis is concerned, the determination of the 
presence or absence of fungi in hair and scales in a doubt- 
ful case of ringworm, favus, chromophytosis or other 
parasitic disease. Happily as between favus and ring- 
worm we seldom have need of the microscope for diag- 
nosis, their symptoms being so pronouncedly different. 
In the hands of the skilled pathologist the microscope is 
constantly adding to our knowledge of diseases of the skin 
and is of great value. 

A few words must be said about the methods of examina- 
tion of patients. They should be always examined by day- 
light or by electric light. It is prudent to refuse to give 
an opinion of a case when seen in a poor light or by arti- 
ficial light. If the patient is a man, it is but just to yourself 
to request him to strip from top to toe, if there is the slight- 
est need of seeing more than the ordinarily exposed parts. 
In the case of a woman such an inspection can seldom be 
made. The same end can be attained by exposing one 
part after the other. In all cases you are justified in 
refusing to treat a case that you have not been given 
ample opportunity to examine. 



THERAPEUTIC NOTES. 45 

All examinations of patients should be made in a warm 
room. The contact of cold with the usually covered skin 
is apt to give it a mottled look that obscures the diagnosis. 
It is well never to give a diagnosis of an obscure case that 
is under local or constitutional treatment, until all treat- 
ment has been suspended for a few days and the disease 
allowed to assume its natural appearance. 

Under the name of diasJcop Unna has recommended the 
use of a small piece of thick, clear glass, marked with a 
measuring scale, for the purpose of exercising pressure 
upon the skin under examination. This does away with 
the confusing redness and brings into greater prominence 
anatomical lesions. 

Every patient should be regarded as possibly out of 
health in some way quite apart from his skin trouble, and 
examined as to the performance of all his functions quite 
as carefully as if he had come to us for the treatment of 
some internal disorder. 



Theeapeutic ISotes. 

In the second part of this book there will be found the 
treatment suitable to the various diseases. In this place 
my object is to give the reader a few notes upon some of 
the newer remedies for skin diseases. At present a new 
remedy is brought out nearly every month that promises 
to do better than any of its predecessors, but careful 
comparative tests demonstrate that many of them are no 
better than the old and tried ones. It is better for the 
general practitioner to learn how to use a few drugs than 
to try every new thing. By practical experience he will 
be surprised to see how much he can accomplish with a 
very small assortment of drugs. 

The old-fashioned excipients for drugs for application 
to the skin were water, lard and oils. Then vaseline and 
cosmoline and other petroleum derivatives were taken up. 
Many of these are disagreeable to use because they are 
greasy. Then liquor gutta perekce (traumaticin) and flex- 



46 GENERAL CONSIDERATIONS. 

ible collodion were introduced, and are still used. They are 
not greasy ; they prevent the clothing from being soiled, 
give us a fixed dressing and exert a certain amount of 
pressure upon the skin that is useful in some cases. They 
are most used in the treatment of psoriasis, ringworm and 
in circumscribed chronic diseases. In acute diseases, and 
specially where there is more or less exudation, they cannot 
be used. 

Plaster muslins were devised by Unna. They are made 
by spreading upon muslin a mixture of gutta percha and 
oleate of alum. With the plaster mass many drugs can 
be combined. 

Salve muslins we also owe to Unna. They consist of a 
salve mass composed of benzoated mutton tallow and wax, 
with which various drugs are combined. The muslin is 
dipped into the melted mass, then dried and rolled flat 
and smooth, either on one or both sides. Machinery is 
used for the purpose. 

Pastes answer admirably for the acute and exudative 
conditions, as they protect the part and at the same time 
allow the exudate to work up through them, and thus 
escape. Lassar's paste, composed of zinc oxide, starch 
and vaseline, as set forth in the formulary at the end of 
this book, was one of the first of these, and is still prob- 
ably more used than any of them. Various other pastes 
have been proposed. It is found that infusorial earth 
(Kieselguhr) added to any ointment in the proportion of 
10 per cent, will form a good paste. 

Salve pencils and paste pencils we owe to Unna. The 
former are composed of wax and olive oil moulded into 
sticks about the size of the little finger. The latter are 
made of starch, tragacanth or gum arabic, with which the 
drug is incorporated into sticks about the size of a slate 
pencil. Neither form of pencil has come into general use. 

Gelatin preparations, one of which is given in the for- 
mulary, were introduced as preferable to ointments, and 
many German and English authorities speak well of 
them. They are troublesome to apply because they have 



THERAPEUTIC NOTES. 47 

to be heated before being used. They have not become 
popular in this country. 

Under the name of skin splints Unna 1 has introduced a 
method of applying dressings in skin diseases that is cer- 
tainly ingenious. Pressure is often wanted. It should be 
even. It is also desirable that such dressings should be 
durable, not readily dislodged, and easily removed and 
replaced. For this purpose the part to be dressed is first 
covered with a layer of plaster- or salve-muslin, or simple 
bandage-muslin. This is painted over with a preparation 
composed of gelatin and glycerin, of each 15 parts ; 
water 40 parts, and oxide of zinc 30 parts. When this is 
set it is painted over with a 10 per cent, solution of 
chromic acid, the green color of which may be covered by 
applying a varnish of zinc oxide and shellac. If a hairy 
part is to be dressed, and it cannot be shaved, the hairs 
should be greased. To remove the dressings it is only 
necessary to raise the edge and to touch the under side of 
the plaster with absorbent cotton wet with benzine. 
Variously medicated salve- or plaster-muslins are to be 
used according to the nature of the case. 

George H. Fox 2 has brought out a series of elastic web- 
bing, broad rings of various sizes, that are admirable for 
retaining dressings in place. They serve the purpose of 
Unna's skin splints without any trouble either to the pa- 
tient or physician. 

In 1891 two excellent excipients were brought to our 
notice : one that is made from gum tragacanth, and called 
Bassorin ; and one that is made from Irish moss, and 
called Plasment. They both sink well into the skin, leav- 
ing a protective film on it that can be readily removed 
with water. 

Medicated soaps, specially those containing an excess 
of fat, have been brought out in great variety during the 
past years, and possess certain virtues, though as a rule a 
soap is not the best vehicle for medication. They are 

1 Monatshefte f. prakt. Dermat., 1893, xvii., p. 481. 

2 New York Med. Journ., 1895, lxii., p. 594, 



48 GENERAL CONSIDERATIONS. 

cleanly, can be readily removed from the skin with water, 
and can be made to produce a greater or less effect accord- 
ing to whether the lather is allowed to remain or not. 

Under the name of oleum physeteris or chwnoceti, a 
species of whale oil was recommended by Guldberg l as 
an excellent excipient. Oleic acid is another vehicle 
that possesses the virtue of penetrating the skin. Lan- 
olin and agnine, derived from wool fat, are among the 
newer greasy applications that are supposed to penetrate 
the skin. Both possess a peculiar odor, unpleasant to 
many. This is most marked in lanolin. It can be 
masked by combining with other ointments and by per- 
fumes, such as rose water. Adeps lance is another of the 
newer bases for ointments. It is said to be unirritating, 
and to be capable of taking up 300 per cent, of water 
without losing its salve-like consistence. Q^sypus, a ref- 
use-product obtained in cleansing sheep wool, belongs to 
the same class of remedies. It is a disagreeable-looking 
stuff with a bad odor, and will not come into favor in 
this country. The property of penetration is not a virtue 
in all cases by any means, as in very many of our cases 
we wish to provide merely protection. 

Resorbin is a mixture of almond oil, wax, water and a 
small amount of a solution of gelatin. It combines readily 
with fats. It is commended for its penetrating powers and 
is said to cool the skin and allay itching and inflammation. 
It is used alone and as an excipient in many diseases of 
the skin. 

Myronin is a yellow, slightly aromatic, butter-like sub- 
stance, for which penetrating powers are claimed. It is 
said to be a good excipient for mercury when used for in- 
unctions and for zinc oxide in intertrigo and dry eczemas. 

In the way of drugs of comparatively recent date we 
have : 

Airol, a combination of bismuth, iodine and gallic acid, 
of gray-green color, odorless and tasteless, which is sup- 
posed to have the virtues of iodoform, though not so 
1 Monatshefte f. prakt. Dermat., 1890, x. 3 No. 10. 



THERAPEUTIC NOTES. 49 

strong. It can be used as a dusting powder or as an oint- 
ment with vaseline. 

Alumnol is a fine, white powder, non-hygroscopic, and 
stable. It is soluble in water to the extent of 45 per cent., 
forming a permanent solution. Used as a powder (12 to 
25 percent.), ointment (1 to 12 per cent.) or in collodion 
(5 to 10 per cent.), it is recommended in acute and chronic 
eczema, various dermatitides, trichophytosis, chromophy- 
tosis and contagious impetigo. 

Anihrarobin was proposed as a substitute for chrysa- 
robin, but it is a weak preparation and has not proved of 
special use. 

Aristol is a good dressing for ulcers used in the form of 
a powder. It is expensive, but a good substitute for iodo- 
form in some cases, as it is devoid of odor. I have made 
many comparative tests with it and older remedies in treat- 
ing ulcers, and have found in the great majority of cases 
that the old friends were the best. In 10 per cent, strength 
it has been commended in the treatment of psoriasis, ery- 
sipelas, hyperidrosis, eczema, acne, rosacea and all sorts of 
ulcers. 

Creolin, in 1 to 5 per cent, solutions in water, is often 
useful in erysipelas, dermatitis and as an antiseptic. It is 
very irritating to some skins. 

Dermatol, a subgallate of bismuth, is said not to cake 
and not to be poisonous. It is used as a powder for fresh 
wounds, forming a crust under which healing takes place. 
For excoriations, intertrigo and slightly moist eczema it is 
to be mixed with equal parts of starch. For large, irri- 
table ulcers it may be used as an ointment of 10 per cent, 
strength or as a powder. 

JEmol is a soft, impalpable powder of delicate pink hue. 
It is analogous to fuller's earth. It softens hard water 
when added to it, and with warm water forms a natural 
soap, leaving the skin feeling pliable and soft. It is said 
to be a good dusting powder and to possess remarkable 
power in separating and causing to fall horny patches of 
eczema and keratosis. For this purpose it is made into a 
4 



50 GENERAL CONSIDERATIONS. 

paste with water, and, when applied, it is covered with 
oiled silk or rubber tissue. 

Europhene. An amorphous powder of yellow color 
and aromatic odor, containing 28 parts of iodine in 100. 
Insoluble in water and glycerin ; readily soluble in ether, 
chloroform, collodion and traumaticin. Useful in venereal 
ulcers and mucous patches in pure powder or 2 to 5 per 
cent, ointment. Also in tertiary syphilis as hypodermic 
injections in the vicinity of the lesion and in solution in 
oil. 

Filmogen is a solution of nitrate of cellulose in acetone 
with enough oil to make it elastic. It is used as an ex- 
cipient for salicylic acid, resorcin, iodoform, pyrogallol, 
bichloride of mercury, chrysarobin, tar, ichthyol and car- 
bolic acid. It holds in suspension sulphur and zinc. 

Fuchsine, and other aniline dyes, in 1 per cent, solution 
in water, are recommended as useful in ringworm, inopera- 
tive cancerous ulcers, erysipelas, and other local infectious 
diseases. 

Gelanthum is a combination of gelatine and tragacanth 
used as an excipient. 

Gallacetophenone, made by the action of acetic acid upon 
pyrogallol, was brought out in 1891 as remarkably effi- 
cient in the treatment of psoriasis. It may be used in 5 
to 10 per cent, strength in ointment or collodion, does not 
stain the clothing and thus far has proved neither poison- 
ous nor very efficacious. 

Hydroxylamine is poisonous when absorbed. It was 
commended for psoriasis, but cannot be used over large 
surfaces. It has been commended in lupus vulgaris and 
ringworm of the scalp and beard, a grain and a half of 
the hydrochloride being dissolved in an ounce and a half 
each of alcohol and glycerin. It has not gained popular 
favor. 

Ichthalbin is a combination of ichthyol and albumen. It 
is tasteless and odorless and usually does not disturb diges- 
tion. It passes through the stomach unchanged, to be split 
up in the intestinal tract. Used internally in doses up to 



THERAPEUTIC NOTES. 51 

60 grains a day in rosacea, eczema, urticaria and pruritus. 

Ichtkyol, especially the animonio-sulphate, is useful, ac- 
cording to its introducer, Unna, and many others, both 
for external and internal use in rosacea, acne, eczema, 
urticaria, erythema, herpes, dermatitis herpetiformis, seb- 
orrhea, furunculosis, erysipelas, psoriasis, sycosis, lupus 
and some other dermatoses. By the mouth it is best 
exhibited in capsules, from three to fifteen drops being 
given during the day. Externally it is exhibited in so- 
lution in water, or in paste-form and in the strength of 2 J 
to 10, 20 or 50 per cent. In a watery solution of 50 per 
cent, strength it is of the greatest value in the treatment 
of erysipelas. 

Liquor anthracis simplex and composites are thin fluids 
prepared from coal tar, which are said to be non-poison- 
ous and to be useful in chromophytosis, trichophytosis 
and chronic eczema. The compound fluid contains sul- 
phur, resorcin and salicylic acid. 

Myronin is a yellow, slightly aromatic substance, of 
butter-like consistence, that is said to be a good excipient 
for ointments. 

Naftalan is a dark colored, empyreumatic, thick mass 
which comes from Armenia. It seems to be useful in all 
diseases in which tar is indicated, but more disagreeable 
to use. 

Naphtol or beta-naphtol is another of the coal tar de- 
rivatives that are useful in seborrheal dermatitis, scabies 
and other diseases. 

Nosophen is a yellowish, odorless and tasteless powder 
used as a dusting powder in ulcers, balanitis, herpes pro- 
genitalis, and wounds. 

Oxynaphthoic acid is recommended by Schwimmer for 
scabies and prurigo in 10 per cent, strength in ointment. 
His ointment for scabies is composed of ten parts each of 
this acid, chalk and green soap, to eighty or one hundred 
parts of lard. 

Resorcin is recommended for seborrhea capitis, begin- 
ning in 2 per cent, strength and increasing up to 5 or 10 



52 GENERAL CONSIDERATIONS. 

per cent., as the acute stage lessens ; for psoriasis, 10 to 20 
per cent. ; eczema about the mouth, 2 per cent. ; erysipelas ; 
and as a plaster for keloid and malignant growths. Strong 
preparations, say 20 to 30 per cent., can be used in acne 
and rosacea for the purpose of producing a dermatitis, to 
be followed by peeling off of the old skin, and in 40 per 
cent, strength is one of the best remedies for lupus ery- 
thematosus. It must be remembered that this drug in 
weak strength promotes cornincation, while in strong so- 
lution it macerates the skin. Remedies of this class are 
called " reducing " agents and to them belong sulphur. 

Salol, two parts to one of starch, is commended for use 
in ulcers. 

Steresol is an antiseptic varnish composed of gum lac, 
benzoin, balsam of tolu dissolved in alcohol, and a small 
amount of carbolic acid or phenol. It is recommended 
especially because it adheres to the mucous membrane as 
well as the skin, and has been found useful in various 
ulcers and in chronic eczema. 

Tar. Compound tincture of coal tar is commended by 
Duhring as a substitute for liquor carbonis detergens. It 
is made by digesting one part of coal tar with six parts of 
tincture of quillaja (1 to 4 in 95 per cent, alcohol). It is 
used diluted, 15 minims to the ounce of water. 

Thilanin is lanolin acted on by sulphur and containing 
3 per cent, of the latter. Recommended for acute and 
chronic eczema, and in lupus erythematosus. 

Thiol, which is miscible with water, and is used in the 
strength of 20 per cent, in liquid or powder form, is said 
to be useful in seborrhoea, rosacea, acne, eczema, burns, 
pemphigus, dermatitis herpetiformis, impetigo, and zoster. 
It is a chemically prepared imitation of ichthyol. As it 
is free from the disagreeable odor of the latter drug it is 
preferable to it in some cases. 

Thiosavonale is a readily soluble sulphur soap. 

Tumenol. Used in solution with equal parts of ether, 
alcohol and water, or glycerin, or in form of paste or oint- 
ment. Useful in moist eczema, burns, ulcers and rhagades. 



CLASSIFICATION. 



53 



Classification. 

In the present state of our knowledge it is impossible to 
make a satisfactory classification of skin diseases. Many 
attempts have been made to do this, and are still being 
made. Nearly every systematic writer tries his hand at 
it, with more or less indifferent success. One of the most 
scholarly classifications is that by Prof. E. B, Bronson, 1 
which is founded on that of Auspitz. Hebra's classifica- 
tion modified is found in a great many text-books. The 
arrangement of this book does away with classification. 
The one here given follows that given by Crocker and has 
proved itself, after a number of years of use, a practical 
one. 

CLASSIFICATION AND NOMENCLATURE. 



Class 


I. 


HYPEE.EMLE. 


a 


II. 


EXUDATIONES. 


it 


III. 


H.EMOEEHAGLE. 


tl 


IV. 


HYPERTROPHIC. 


a 


V. 


ATROPHIA. 


a 


VI. 


NEOPLASM ATA. 


it 


VII. 


NEUEOSES. 


'• 


VIII. 


MOEBI APPENDICIUM. 


it 


IX. 


PAEASITI. 


Class I. 


HYPER^EMLE— CONGESTIONS. 


Erythema simplex. 
' ' pernio. 
" intertrigo. 
' ' scarlatinifoi 
" fugax. 
' ' roseola. 


me. 


Most -prominent 'primary lesion 

Erythema. 
a 

it 

n 

it 



Class II. EXUDATIONES— INFLAMMATIONS. 

Most prominent primary lesion. 
Erythema exudativum multiforme. 



Erythema and papules. 
" " tubercles. 

" vesicles. 

Journ. Cutan. and Gen.-Urin. DL-;., 1887, v., 369. 



a. papulosum. 

b. tuberculosum. 

c. circinatum. 



54 



GENERAL CONSIDERATIONS. 



d. bullosum. 

e. nodosum. 
/. iris. 

Pellagra. 
Acrodynia. 
Urticaria. 
Eczema. 

a. erythematosum. 

b. papillosum. 

c. vesiculosum. 

d. pustulosum. 

e. rubrum, seu madidans. 
/. squamosum. 

g. verrucosum. 
Dermatitis seborrhoica. 
Dermatitis repens. 

Impetigo. 
Ecthyma. 
Pompholyx. 
Herpes. 

a. facialis. 

b. progenitalis. 
Zoster. 
Pemphigus. 

a. vulgaris. 

b. foliaceus. 
Epidermolysis. 
Equinia. 

Hydroa, seu Dermatitis herpeti- 
formis. 
Impetigo herpetiformis. 
Dermatitis. 

a. calorica, 

b. traumatica. 

c. medicamentosa. 

d. venenata. 
Dermatitis epidemica. 
Psoriasis. 

Pityriasis rubra, seu Dermatitis ex- 
foliativa. 
Pityriasis rosea. 

Lichen scrofulosorum. 

' ' pilaris. 

' ' planus. 

' ' ruber. 
Pityriasis rubra pilaris. 
Prurigo. 

a. mitis. 

b. ferox. 



Most 'prominent primary lesion. 
Erythema and bullae. 

" " nodes. 

" " vesicles. 



Wheals. 
Multiform lesions. 



Eedness and scaling. 
Epidermic denudation and fluid ex- 
udation. 
Vesicles and pustules. 
Large vesicles and pustules. 
Bullae and vesicles. 
Grouped vesicles. 



Grouped vesicles. 
Bullae. 



Bullae. 
Multiple lesions. 

Grouped multiform lesions. 
Grouped pustules. 
Multiform lesions. 



Erythema and papules. 
Scaly crusts on red base. 

Diffuse redness with large scales. 
Oval, scaly, reel patches, with yel- 
lowish center. 
Papules, grouped. 

' ' follicular. 

" flat, angular. 

" acuminate, scaly. 

It U u 

' ' lenticular. 






CLASSIFICATION. 



55 



Most prominent primary lesion. 
Furunculus. Phlegmonous. 

Carbuneulus. ' ' 

Abscess. ' ' 

Pustula maligna. ' ' 

Llcus. Loss of substance. 

Erysipelas. Erythema with brawny swelling. 

Conglomerative pustular folliculitis. Patches of aggregated pustules. 
Dermatitis gangrenosa. Gangrene. 



Class III. BLEMOEEHAGLE— HEMORRHAGES. 
Blood extravasation. 



Purpura. 

a. simplex. 

b. haeinorrhagica. 

c. rheumatica. 
Scorbutus. 



Blood extravasation. 



Class IV. HYPEETEOPHLE— HYPEETEOPHIES. 



Ichthyosis. 

Keratosis pilaris. 

Acanthosis nigricans. 

Verruca. 

Porokeratosis. 

Clavus. 

Cornu cutaneum. 

Callositas. 

Tylosis. 

Scleroderma. 

Morphoea. 

Sclerema neonatorum. 

(Edema ' ' 

Elephantiasis. 

Acromegaly. 

Chloasma. 

Lentigo. 

Kaevus pigmentosus. 



Parts affected. 
Epidermis and papillae. 
Papules about hair follicles. 
Epidermis and papillae. 



Epidermis. 
Corium. 



Whole skin. 
Pigment. 



Class V. ATEOPHLE— ATEOPHIES. 



Albinismus. 
Leucoderma. 
Atrophia cutis propria. 
Atrophoderma senilis. 

striatum et macula- 
turn. 
Atrophoderma pigmentosum. 
Ulcus perforans. 
Ainhum. 



Parts affected. 
Pigment, deficiency, disturbance. 

it a a 

Corium. 



56 GENERAL CONSIDERATIONS. 



Class VI. NEOPLASMATA— NEW GROWTHS. 

Keratosis follicularis. Crusted papules. 

Molluscum 1 

Colloid Degeneration V Degeneration. 

Xanthoma J 



Lupus vulgaris 

' ' erythematosus 
Scrofuloderma 
Tuberculosis 

verrucosa cutis 
Syphiloderma 

a. eiythematosum 

b. papulosum 

c. pustulosum \ Infiltrating. 

d. tuberculosum 

e. gummatosum 
Lepra 

a. ansesthetica 

b. maculosa 

c. tuberosa 
Rhinoscleroma 
Leucoplakia 



Keloid \ 
Fibroma 1 

Acrochordon j 

Myoma / 

Neuroma f 

Nsevus vasculosus l > t> • 

Telangiectasis / ° 



Angioma serpiginosum 

Angiokeratoma 

Rosacea 

Lymphangioma 

Dermatolysis 



Carcinoma 

Paget' s disease 

Epithelioma 

Sarcoma 

Mycosis fungoides ) Malignant. 

Yaws 

Verruga Peruana 

Furunculus orientalis 

Phagedena tropica 



CLASSIFICA TION. 



57 



Class VII. NEUROSES— SENSORY DISEASES. 



Hyperesthesia. 
Dermatalgia. 
Pruritus. 
Anaesthesia. 



Class VIII. MORBI 



APPENDICIUM- 
APPENDAGES. 



-DISEASES OF THE 



A. Sweat Glands. 
Hyperidrosis. 
Bromidrosis 
Chromidrosis 
Haematidrosis 
Uridrosis 
Anidrosis. 

Miliaria crystallina (sudamina). 
Miliaria papulosa. 
Hydrocystoma. 

B. Sebaceous Glands. 
Seborrhcea. 

a. oleosa. 
h. sicca. 
Milium. 
Comedones. 
Acne vulgaris. 

" indurata. 

" varioliformis. 
Sebaceous cyst. 
Adenoma sebaceum. 
Asteatosis. 

C. Hair. 

Hypertrichosis. 

Atrophia. 

Alopecia. 

areata. 
Keratosis pilaris. 
Concretions. 
Trichorrhexis nodosa. 
Canities. 
Sycosis. 

Folliculitis decalvans. 
Dermatitis papillaris capillitii. 
Nsevus pilosus. 

Plica Polonica. 

Trichiasis. 

Distichiasis. 



Most prominent primary lesion. 
Excessive secretion. 

' Altered quality. 

Deficient secretion. 
Vesicles. 
Inflammation. 
Vesicles. 



Excessive secretion. 

Retained secretion. 
Inflammation. 



Retained secretion. 
Papules. 
Deficient secretion. 



Excessive growth. 
Defective growth. 
Baldness. 

in patches. 
Retention. 

Growths on the hair shaft. 
Nodes on hair shaft. 
Loss of pigment. 
Inflammation. 

Alopecia with inflammation. 
Inflammation. 

Excessive growth with pigmenta- 
tion. 
Felting. 
Misplacement of cilia. 



58 GENERAL CONSIDERATIONS. 

D. Nails. Most 'prominent primary lesion. 

Pterygium. Overlapping of nail fold. 

Onychia. Inflammation. 
Paronychia. ' ' 

Atrophia. Defective growth. 

Onychogryphosis. Overgrowth. 

Leucopathia unguium. White spots in nails. 

Class IX. PAEASITI— PAKASITES. 

A. Vegetable. 

Favus. Parasite — Achorion. 
Trichophytosis. " ■ — Trichophyton. 

a. barbae. 

b. capitis. 

c. corporis. 

d. cruris. 

e. unguium. 

Chromophytosis (tinea versicolor). Parasite — Microsporon. 

Erythrasma. " — Microsporon minutissimum. 

Mycetoma. Tumors. 

Actinomycosis. ' ' 

Pinta. Discolored macules. 

B. Animal. 

Scabies. Parasite — Acorns. 
Pediculosis. ( ' — Pediculus. 

a. capitis. 

b. corporis. 

c. pubis. 

Cysticercus cellulosse cutis. Parasite — Tcenia solium. 
Dracontiosis. ' ' — Filaria medinensis. 



Some Dermatological Dont's. 

Don't make your diagnosis from the history of a case, 
because if you do you will often be led astray. Make it 
from the eruption that you see, and then substantiate or 
destroy this by the history of the case, if you will. 

Don't fail to think of the possibility of every case being 
either syphilis or eczema ; and 

Don't fail to master these two diseases as thoroughly as 
possible, because if you learn to recognize these two you 
will have gone a long way in diagnosis. If they can be 
excluded, then the field of possible " might be's " is con- 
siderably narrowed. 

Don't make the diagnosis of syphilis on account of a 



SOME DERMATOLOGICAL DONT'S. 59 

syphilitic history, because you can often get a history of 
syphilis in a non-syphilitic case. 

Don't expect much, if any, history of syphilis in a 
woman, because you very frequently will not get it. In 
them the early symptoms of the disease are often so slight 
that they are not observed by them. 

Don't throw out the diagnosis of syphilis on account 
of an eruption itching, because some syphilides, especially 
the papular variety, do itch at times. The not itching of 
an eruption is better presumptive evidence of syphilis 
than is itching positive evidence against it. 

Don't make the diagnosis of lichen planus from the 
presence of flat angular papules with depressed centers 
alone, because identical lesions will at times be met with 
in eczema, syphilis and psoriasis. 

Don't depend upon getting the bleeding points spring- 
ing out of the delicate pellicle after carefully scraping off 
the scales, for your diagnosis of psoriasis, because you 
can produce the same thing in other diseases. In fact, 

Don't depend upon any one symptom, but make your 
diagnosis from the general make-up of the disease as a 
whole. 

Don't forget that many diseases of the skin are depend- 
ent upon disturbances in the general health of the pa- 
tient. Therefore, 

Don't fail to inquire into the performance of the func- 
tions of the various organs of the patient, and to put 
him into as good a physical condition as possible. 

Don't tell your patient that it is dangerous to cure his 
skin disease rapidly, because it is not. If you 

Don't know how to treat the case, ask advice of some- 
one who does. 

Don't encourage the popular notion that there is danger 
of an eruption striking in, because it never does. 

Don't give arsenic for every skin disease, and, es- 
pecially, 

Don't give it in acute eruptions. Its sphere is in the 
chronic scaly eruptions, such as chronic psoriasis. 



60 GENERAL CONSIDERATIONS. 

Don't forget that most cases of pruritus are due to in- 
ternal causes, and that in them external treatment is 
wasted ; and 

Don't forget the bedbug and the pediculus as possible 
causes of the trouble. 

Don't forget that the greatest secret in the treatment of 
eczema, and many other skin diseases, is not what par- 
ticular drug or formula is " good for " the disease, but a 
knowledge of the great principle that acute diseases need 
soothing remedies and subacute and chronic diseases need 
stimulation. 

Don't expect to cure an inveterate eczema with thick- 
ened skin by means of a soothing ointment, such as that 
of the oxide of zinc, because you will only waste your 
time and the patient's money. 

Don't use tar in an acute eczema, because it is a stimu- 
lant, and what we want at this time is to soothe the in- 
flamed skin. It is appropriate in a subacute or chronic case. 

Don't allow water to touch the skin in acute eczema, 
because it always irritates in such a case. 

Don't use a thick ointment on the hairy scalp, because 
it makes a disagreeable mess of the hair, and will not be 
" popular " with your patient. Even lard is not a pleas- 
ant vehicle for such applications. Vaseline and the oils 
are more elegant excipients. 

Don't order the hair to be cut from the head of a young 
or old woman in any disease of the scalp, because, except 
in the case of a peculiarly stupid or careless patient, it is 
never necessary, and always disagreeable to the woman. 

Don't allow a patient with ringworm to go to school, 
because if you do you will be responsible for the spread 
of the disease. 

Don't pronounce a ringworm case well and incapable 
of spreading the contagion until you are sure that it is 
well ; and 

Don't be sure about it until there are no more " stumps " 
on the scalp, and you can find no more of the fungus in 
the hair. 



SOME DERMATOLOGICAL DONTS. 61 

Don't use the name " barber's itch " for anything but 
trichophytosis barbae, because it is well not to use terms 
loosely to cover several different diseases. 

Don't use chrysarobin on the face or scalp, because it is 
very apt to cause a good deal of dermatitis with oedema 
and to stain the skin a deep mahogany-red. 

Don't forget to caution a patient to whom you have 
given chrysarobin not to touch his face with his hands 
after applying the drug, because if you do you will have 
either a mad or a frightened patient in your office. 

Don't pronounce a patient addicted to the excessive use 
of alcoholic beverages on account of his having rosacea, 
because there are lots of other things besides alcohol that 
will cause it. 

Don't use the positive pole of the battery for the needle 
in destroying hair by electrolysis, because if you do you 
leave more or less permanent marks in the skin. 

Don't apply a sulphur preparation after using a mer- 
curial upon the face, or vice versa, because if you do you 
will raise a fine crop of comedones. 

Don't use a camel's hair brush for making applications 
of corrosive sublimate, because if you do some of the salt 
will be left on the brush each time it is used, and you 
will soon have a stronger solution than you bargained 
for. Always use a little cotton on a wooden toothpick 
or a splinter of wood. 

Don't allow a fine toothed comb to be used on the scalp, 
because it scratches and irritates the scalp. 

Don't encourage or advise the use of pomades on the 
healthy scalp, because they are prone to become rancid 
and inflame the scalp. They are also unnecessary if the 
hygiene of the scalp is properly looked after. 

Don't forget that dandruff is the most frequent cause 
of premature baldness, because if you remember this you 
may be able to prevent the fall of some one's hair for 
some time. Therefore, 

Don't fail to treat every case of dandruff. — 2 he Med- 
ical Record, December 29, 1888. 



PART II. 

THE DISEASES OF THE SKIN AND THEIK 
TREATMENT. 



Scheme of Pronunciation. 

A, ape ; A 2 , at ; A 3 , ah ; A 4 , all ; Ch, chin ; Ch 2 , loch (Scottish) ; E, he ; 
E 2 , ell ; G, go ; I, die ; I 2 , in ; N, in ; N 2 , tank ; O, no ; O 2 , not ; 
O 3 , whole ; Th, thin ; Th 2 , the ; U, like oo in too ; U 2 , blue ; U 3 , 
lull ; U 4 , full ; U 5 , urn ; U 6 , like ii (German). 1 



Abscess (AV-seV). 

Symptoms. Abscesses are very frequently met with as 
complications of diseases of the skin, such as acne, eczema, 
scabies, pediculosis and other acute dermatitides. As 
thus met with, they are usually of small size, though at 
times, as upon the scalp of a strumous child, they may 
attain considerable dimensions. They form rounded 
swellings that are at first tense but soon become soft and 
fluctuating. When incised a lot of more or less thick pus 
escapes. Their most frequent locations are : upon the 
scalp with eczema ; upon the face and back with acne ; 
and upon the extremities with scabies and pediculosis. 
Apart from a slight amount of discomfort, they do not 
give rise to subjective symptoms as a rule, and are, indeed, 
trivial affections. Of course, this does not apply to ab- 
scesses as seen by the surgeon. They may open of them- 
selves, and discharge their contents upon the skin. More 
commonly they are very sluggish in their course, and must 
be evacuated by some surgical procedure. 

1 From Foster' s Illustrated Encyclopaedic Medical Dictionary. New 
York, 1890. By permission. 

62 



ACANTHOSIS NIGRICANS. 63 

Diagnosis. An abscess differs from a furuncle by not 
being raised ; not having a central core, and by being less 
firm to the touch. It differs from a carbuncle by an entire 
absence of marked constitutional disturbance, brawny in- 
filtration, intense inflammation, and cribriform mode of 
opening. Kerion often resembles an abscess, but differs 
from it in its uneven surface and its firmness to the touch. 
Syphilitic gummata are sometimes mistaken for abscesses 
and opened. They may be recognized by their dark-red 
color, their absence of pain and discomfort, and the his- 
tory of their growth. They grow slowly, beginning below 
the skin. There is generally more than one present, and 
then they are grouped. The aspiration of the tumor will 
decide the question. From an abscess we obtain pus ; 
from a gumma a little bloody fluid. 

Treatment. The management of the small cutaneous 
abscesses that we meet with as dermatologists is simple. 
The cavity is to be opened, the pus allowed to escape, and 
the part dressed with carbolized vaseline if small, or an- 
tiseptically if larger. It is sometimes necessary to swab 
out the cavity with a strong carbolic acid solution to de- 
stroy the abscess wall and prevent the re-formation of 
the abscess. 

Abscess Sudoripares. See Hidrosadenitis suppurativa. 

Abschilferung" (A^'-shrl-fe^-ung). Branny scaling of 
skin. 

Abschuppung (A 3 b'-shup-pung). Scaling or chapping. 

Acantholysis (A 2 k-a 2 n-tho 2 l r -i 2 -si 2 s). A disease char- 
acterized by loosening or separation of the mucous layer 
of the epidermis. See Epidermolysis. 

Acanthosis Nigricans (A 2 k-a 2 n-tho r -si 2 s Xi 2 g-ri 2 k-a 2 ns). 
Under this name cases have been reported by Pollitzer, 
Janovsky, Crocker and a few others. It consists in a 
dirty-brown to bluish-gray discoloration of the skin and 
mucous membranes, with more or less papillary out- 
growths. On the places that are most discolored the 
papillary outgrowths are most marked. The skin is 



64 DISEASES OF THE SKIN. 

thickened to a greater or less degree. The regions af- 
fected are the face, neck, mucous membranes of the mouth, 
the backs of the hands, especially the fingers, the axilla?, 
groins, genito-anal regions and abdomen. Treatment 
does not seem to be of any use. The cause of the dis- 
ease is unknown. Eille 1 regards it as a form of keratosis. 

Acne (A 2 k'-ne). Synonyms : Varus, Ionthus ; (Ger.) 
Finnen ; (Fr.) Acne, Bouton ; Stone-pock, Whelk, Pimple. 

Acne is an inflammatory disease of the sebaceous glands 
and the hair follicles, due to the retention of sebum ; char- 
acterized by an eruption of papules, pustules or tubercles 
upon the face, neck, shoulders or chest, which usually 
begins at puberty and tends to run a chronic course. 

Different writers and teachers have applied different 
names to the different phases of acne. These had best be 
forgotten, except in so far as they are of historical value. 
The term acne is applied by the French school to all dis- 
eases of the sebaceous glands. It would seem to be the 
wiser plan to reserve the name for the disease just defined. 
Regarded thus, we have but two varieties of true acne, and 
those are acne vulgaris and acne indurata. 

Acne Vulgaris, or Simplex, is either papular or pustular 
in character, though usually it is a combination of the two, 
together with more or less comedones scattered about. 

Symptoms. If only papules exist (A. papulosa), the 
face, shoulders or chest will be found to be dotted more or 
less profusely with pinhead-sized, acuminated elevations of 
the skin, Qf a pinkish to red color and with a central open- 
ing at the summit. Very often the central openings will 
be filled by blackish specks. The lesions are then spoken 
of as A. punctata. This term is used by some writers to 
designate the comedo, but improperly, according to our 
definition. It is rare that acne exists only in the papular 
form. More usually it will be found that here and there 
the papules are surmounted by a pustule, or a pustule has 
taken the place of a papule. We now have A. pustulosa. 

^Wien. Med. Wochschr., 1897, xlvii., 1019. 



ACNE. 



65 



In strumous subjects the pustular element preponderates 
over the papular and the face may be greatly disfigured 
by the large number of the lesions present upon it. The 
pustules are from pinhead to small-pea size and have an 
inflamed base. (Fig. 5.) 

Together with the acne and the comedones, we meet with 
milia quite commonly, and the affected parts are usually 

Fig. 5. 




Acne vulgaris. 
(From Prof. George H. Fox's Service in the Vanderbilt Clinic.) 

greasy to the feel, showing that the sebaceous glands sym- 
pathize in the disease. We now have a fair picture of a 
typical case of acne vulgaris. The face, back, neck or 
chest, or all four, are dotted over in an irregular manner 
with blackish points, papules and small pustules ; the skin 
of the nose and forehead looks shiny and feels greasy, and 
5 



66 DISEASES OF THE SKIN. 

perhaps there are some milia scattered about the region of 
the eyes. At times the face will look inflamed and hyper- 
semic, especially in young, otherwise robust, subjects. More 
commonly the complexion will have that pasty appearance 
indicative of what has from old times been called the 
strumous condition. If the inflammatory process has been 
unusually severe we may find a considerable amount of 
scarring. Usually acne vulgaris does not leave permanent 
scars. The profuseness of the eruption varies greatly. In 
some cases there will be but a few lesions, while in other 
cases they will be present in vast amount. This form of 
acne generally occurs in young people. The duration of 
the individual lesion is short, as it soon either dries up or 
discharges its contents. If the papules are squeezed little 
plugs of sebaceous matter will be expressed. If the 
papulo-pustules are treated in the same way there will 
first be pressed out a small sebaceous plug and then a drop 
or two of pus. 

Acne Indurata is a pustular acne in which the pustules 
are of large size and seated upon deeply infiltrated bases. 

They are most commonly sparsely dispersed and take 
the form of purplish " lumps " of pea to bean size which 
are hard to the touch. Sometimes they are more readily 
appreciated by touch than by sight, being located deeply 
in the skin. Sometimes they take the form of cutaneous 
abscesses, and if by chance several are located close to one 
another they may run together and form a raised, dark- 
red, doughy mass. When incised, these lesions sometimes 
give exit to a large amount of thick pus. They usually 
leave scars, which sometimes are very disfiguring, unless 
they are opened very early in their course. It may be 
the only form of acne present, or it may be combined 
with acne vulgaris. This form of acne usually occurs at 
a more advanced age than does acne vulgaris, though it is 
not infrequently met with in early life. While occurring 
on the face, the neck and back are the regions in which it 
is prone to develop in the most marked manner. (Fig. 6.) 

Etiology. Acne is one of the most common of skin 



ACNE. 67 

diseases, and its great predisposing cause is youth. The 
disease first shows itself about the time of puberty and 
manifests a tendency to disappear when the body is fully 
developed — that is, from the twenty-third to thirtieth year. 
A few rare cases have been reported of acne at an early 
age. Thus, Chambard l has met with a case in a girl of 
six and a half years. The indurated form of acne appears 
later than the simple form, usually after the twenty-fifth 

Fig. 6. 



/ 






Acne indurata of the back. 



year. Both sexes are affected, but the disease is more fre- 
quent in females than in males and in them begins at an 
earlier age. The period of youth is the time of great de- 
velopmental activity in which the sebaceous glands take 
part, and it is probable that there is a too great activity 
of the glands and an improperly formed sebum is the re- 
sult. Normally, the product of the fat-glands is an oily 

1 Ann. de derm, et syph., 1878-79, x., 259. 



68 DISEASES OF THE SKIN. 

fat. In acne an inspissation of the fat takes place, form- 
ing a ping that acts as a foreign body and sets np an in- 
flammation. 

Individuals with thick, pasty, pale skins, with patulous 
follicular mouths are predisposed to acne. These pecu- 
liarities of skin are met with in scrofulous subjects. The 
patulous follicular mouths give ready lodgement to foreign 
matters and comedones are thus formed. This prevents 
the escape of the follicular contents, a plug is formed and 
we have an acne papule or pustule. Comedones are, 
therefore, an exciting cause of acne. 

Heredity has been asserted by some to be a predis- 
posing cause of acne, but the disease is so common that 
there is no certainty about this factor. 

Of the exciting causes of acne, the most active one is 
some form of digestive disturbance. This may take the 
form of dyspepsia, stomachal or intestinal ; or it may be 
mal-assimilation ; or it may be failure on the part of the 
liver or pancreas to perform its physiological functions ; 
or it may be sluggishness of the large intestine and con- 
sequent constipation. 

Next to disorders of the digestive organs, those of the 
sexual organs are supposed to have most influence in pro- 
ducing acne. But, inasmuch as most cases of acne are 
amenable to the influence of diet and regulation of diges- 
tive disorders without any attention being given to sexual 
disorders, it is probable that the latter are important eti- 
ological factors in comparatively few cases. Indeed, it is 
not improbable that the acne that appears on the faces of 
women at each menstrual period, and at that time alone, 
as well as the aggravation of an already existing acne, is 
due to the more or less pronounced disturbance of the 
digestive organs so frequently observed at the same time. 
In some cases acne does seem to be a reflex irritation 
from the uterus. Amenorrhoea is the uterine derange- 
ment most frequently encountered, but that condition is 
but one evidence of a general constitutional disorder, 
rather than a disease in itself. 






ACNE. 69 

Masturbation and continence have each been blamed as 
excitants of acne. The former of these of itself does not 
cause acne, but its well-known effects on the nervous, 
moral and physical condition of growing youths would 
sufficiently account for any part it may have in producing 
acne. There is absolutely no proof that continence causes 
acne. If a boy or young man keeps himself in a constant 
state of unrest by lascivious thoughts, that is not true con- 
tinence, even though he does not masturbate or copulate. 
It is safer for us to say that bad sexual hygiene may cause 
acne, rather than to ascribe it either to masturbation on 
the one hand or continence on the other. 

It may be stated, as a broad general rule, that anything 
that lowers the general health of the patient contributes 
to the production of acne. We have space to enumerate 
only some of these exciting causes. Thus, we have the 
vague state " general debility/' anaemia and chlorosis, ox- 
aluria and uraemia, rheumatism and gout, poor circulation, 
mental and physical exhaustion and chronic malaria. 

In 1881 Denslow 1 advanced the theory that a want of 
tone in the arrectores pilorum muscles, either alone or to- 
gether with an over-production of sebaceous matter, and 
its retention in the sebaceous glands, was an important 
etiological factor in acne. As the muscles failed to act 
with sufficient vigor, they did not perform one of their 
offices — the emptying of the follicles — and this allowed 
of the retention of glandular products and consequent 
acne. 

' Acne of the pustular variety is said to be due to the 
entrance of the staphylococcus aureus et albus into the 
follicles, which offer proper ground for its growth. Unna 
believes that there are several forms of micro-organisms 
found in the comedones and that one, a small bacillus, is 
the cause of the disease. He regards the usually accepted 
systemic causes of acne as only aggravants of the disease 
and teaches that the disease is a purely local one. His 
views have been largely accepted. 

1 New York Med. Joum., 1881, xxxiii., 189. 



70 DISEASES OF TEE SKIN. 

Pathology. Acne may begin in the hair follicles or 
in the sebaceous gland, and may be due either to their 
becoming clogged up by inspissated sebum and acting like 
a thorn in the flesh, or to their invasion by micro-organ- 
isms, either from without or within, which set up a sup- 
purative perifolliculitis. The papules of acne are located 
in the upper part of the skin, while the pustules are 
deeper. In very bad cases the follicle may be entirely 
destroyed by the perifolliculitis and scars will be left. 
The sebaceous glands do not take a very active part in 
the process. Micro-organisms are found abundantly in 
the suppurating gland cavities. 

In acne indurata we find the hair follicle enormously 
dilated, its orifice filled with corneous cells, and its cavity 
almost converted into a cyst. The connective tissue about 
the follicle shows decided signs of inflammation and may 
be increased in amount. Very often the follicle is de- 
stroyed by the perifollicular inflammation. When the 
perifolliculitis is severe and extensive the deep layers of 
the skin become involved, and we have abscess formation. 

Diagnosis. Acne is to be differentiated from rosacea, 
papular and pustular eczema, sycosis, the small pustular 
and tubercular syphiloderm and variola. 

Rosacea is due to a dilatation of the blood vessels, and 
is attended by hyperemia and telangiectases. If there 
are any pustules they are superficial, and if excised give 
exit to only a drop of pus. Acne is a disease- of the 
sebaceous glands, and papules and pustules constitute the 
disease. They are often large, and if excised will give 
exit to a plug of sebaceous matter and thick pus. Ro- 
sacea, as a rule, occupies the middle third of the face alone, 
the forehead, nose, and chin. Acne is scattered over the 
whole face, and is often found on the shoulders. 

Papular eczema may occur at any age ; acne usually oc- 
curs between the ages of fifteen and twenty-five. Papular 
eczema rarely is seen on the face alone, and is prone to 
attack the trunk and extremities. Acne often occurs on 
the face alone, and is never disseminated over the limbs 



ACNE. 71 

and trunk. In eczema there is an absence of comedones ; 
the papules are often surmounted by or change into 
vesicles ; they tend to form patches, and the disease is 
very itchy, so that scratch marks are almost invariably 
found. When it gets well it leaves no trace on the skin. 
These symptoms are foreign to acne. 

In pustular eczema, or what has been called impetigo 
simplex, we have a large number of small pustules run- 
ning together to form patches which rapidly become 
covered with greenish or yellow crusts. The disease 
runs a far more acute and stormy course than does acne, 
and is itchy. It is very frequently met with in children, 
whom acne rarely affects. 

Sycosis is a pustular disease affecting the hair follicles 
alone, each pustule being pierced by a hair. Acne occurs 
on the non-hairy as well as the hairy parts, and, indeed, 
shows preference for regions supplied only with rudi- 
mentary hairs. 

The small pustular sypliiloderm, or syphilitic acne, is a 
general eruption, and it is easy in most cases to obtain 
other evidences of syphilis, such as the remains of the 
initial lesion, enlarged lymphatic glands, mucous patches, 
or the like. It is usually more uniform in its lesions, 
and these are plainly papulo-pustular. The color of the 
areola is more that of raw ham, and less inflammatory- 
looking than is that of acne. The lesions sometimes show 
a tendency to group into segments of circles, and each 
lesion undergoes a definite development. They sometimes 
leave small, smooth, white scars that may disappear in a 
few months. The tubercular syphiloderm could be mis- 
taken for an indurated acne. In it there will usually be 
found other evidences of syphilis. The lesions group 
themselves into patches that are kidney-shaped or form 
segments of circles. The tubercles are dark-red or raw- 
ham colored, surrounded by a well-marked areola, firm to 
the touch, and do not contain pus. They may ulcerate, 
or, being absorbed, leave pigmented and punched-out 
cicatrices, and, finally, smooth white scars. The scars 



72 DISEASES OF THE SKIN. 

left by acne indurata are puckered and more disfiguring. 

Variola could scarcely give rise to much doubt, as it 
has well-marked constitutional symptoms, and its lesions 
undergo a definite and characteristic development. 

Treatment. In the treatment of acne we can obtain 
a cure most surely by attention to the general condition 
of the patient • most rapidly by a combination of internal 
and local treatment. Of course, in cases where only a 
single pustule crops out, as in some women at each men- 
strual period, there is no need for any treatment. But 
such are not those that ask our aid. 

We, therefore, begin the treatment of a case by a careful 
inquiry into the general condition of the patient, and 
endeavor to regulate any, even the slightest, derangement 
of the internal organs. By so doing we may find no one 
of those conditions enumerated under the etiology of the 
affection, and the patient may consider himself as in the 
best conditon. Further observation will probably reveal 
some deviation, though slight, from perfect health. The 
relief of constitutional disorders is conducted according to 
the principles of general medicine, and cannot be given 
here. Many of the cases require cod-liver oil and iron as 
general measures quite apart from any evident disease. 
This is seen in the sluggish cases occurring in strumous 
subjects with pasty skins. In plethoric subjects with a 
good deal of inflammation attending the acne, laxative 
agents, such as a tenth of a grain of calomel in tablet tritu- 
rates, given three or four times a day, will aid in a cure, 
quite aside from any constipation. 

Diet and hygiene are agents to be employed rather 
than drugs. It is impossible for us to lay down fixed 
principles of diet, and it is better to study each case by 
itself. The well-to-do are all prone to eat too much, and 
it is remarkable how rapidly their acne will improve by 
reducing their diet to the simplest elements. In many of 
them a milk diet for a few days, provided milk agrees 
with them, will accomplish a marked benefit. It is a 
good rule to cut off from the dietary all pastry, cake, 






ACNE. 73 

candy, sweets, hot breads and pancakes, greasy soups, 
articles fried in fat, rich gravies — in fact, all those things 
that are most apt to tempt the palate. Oatmeal is often 
cited as a cause of acne. Hot water before meals, a 
glass of fluid, either milk or water, at meals, and a glass 
of water two hours after meals, is a good direction for the 
use of things to drink. Tea, coffee, malt liquors, sweet 
and heavy wines are to be avoided. Butter may be used 
freely, and care must be had not to restrict too greatly the 
diet. Many young girls almost starve themselves, on 
the mistaken idea that a low diet will give them a fine 
complexion. Exercise must be insisted on, an hour or 
more a day being spent in walking, horseback or bicycle 
riding, rowing or other out-door exercise. Daily bath- 
ing or dry rubbing will keep the skin in healthy condi- 
tion and Turkish baths are often beneficial. Where pa- 
tients either can not or will not take a daily bath much 
good will be accomplished by having them bathe the chest 
and back daily with cold water and then dry the skin by 
brisk rubbing with a coarse towel. 

Arsenic, sulphide of calcium, glycerin and ergot are the 
drugs that are given by the mouth as curative in acne. 
Arsenic is the oldest and most honored of these. It is of 
use in only very chronic, sluggish cases, and the more 
papular the case the more useful the arsenic. It should 
be used as the last resort, not as the first, Fowler's so- 
lution is the most frequently used preparation, in doses of 
from three drops three times a day, as an initial dose, 
gradually increased to fifteen or twenty drops or until the 
appearance of some symptoms of poisoning. Piifard 1 
recommends bromide of arsenic in the dose of -4^ to A 
gram two or three times a day m rather acute cases of 
acne. A convenient method of administration is to make 
a one per cent, solution in alcohol, and give one or two 
minims of that in a wineglassful of water. Should it 
cause gastric irritation the dose must be lessened. I have 
used this in a number of cases and with good results. 
1 Journ. Cutan. and Yen. Dis/, 1884, ii., 71. 



74 DISEASES OF THE SKIN. 

The sulphide of calcium will be useful in many sluggish 
pustular cases. It should be given in small doses, from 
TlTo" *° iV g ram ? m gelatin-coated pills or fresh tablet 
triturates. One pill may be given four or five times a 
day until the tendency to pustulation is increased. It 
then should be discontinued until the exacerbation has 
subsided, when it should be again administered. Glycerin 
was advocated by Gubler x as a cure for acne, and is Avell 
spoken of by others. It must be given in doses of a tea- 
spoonful three times a day increased to a tablespoonful, 
and is of most use in strumous cases. Ergot, either the 
fluid extract in doses of half a drachm three times a day 
or a corresponding amount of ergo tin, has many advocates. 

Ohrysarobin, internally, has been recommended by Stoc- 
quart, 2 in the dose of one-sixth to one-half a grain. Small 
doses of the bichloride of mercury are sometimes curative 
where there is much infiltration. Sherwell 3 advocates the 
passage of the cold sound through the urethra of a young 
man suffering with acne. Hot vaginal douches are rec- 
ommended by some in acne of women. 

The objects of local treatment are to open up the pus- 
tules and papules and allow of the escape of their con- 
tents, to stimulate the skin to a more healthful action, 
and, according to the bacteriologists, to prevent further 
infection of the follicles by micro-organisms. To attain 
the first two objects we may employ either a quick or a 
slow method ; to attain the last object we employ an anti- 
parasitic. The best preventive local treatment is to keep 
the skin clean and its nutrition good by the use of soap 
and water. 

A most efficient local treatment for nearly all cases of 
acne is to put the skin somewhat on the stretch and scrape 
it somewhat roughly with a large and long, blunt dermal 
curette with a fenestrated blade (Fig. 7). This tears off all 
the tops of the lesions, presses out all the contents of the 

1 Journ. de Bruxelles, 1870. 

2 Ann. dederm. et syph. ; 1884, v., 15. 

3 Journ. Cutan. and Yen. Dis., 1884, ii., 335. 



ACNE. 75 

follicles and stimulates the skin in a most vigorous manner. 
It is followed by some bleeding, which it is well to encour- 
age by the use of warm water. Deep pustules or cutaneous 
abscesses, if not emptied by the curetting, should be incised. 

Fig. 7. 



Fox's ring curette. 

All comedones should be squeezed out. The after-treatment 
consists in washing the face with warm water and soap and 
dusting with cornstarch, to which may be added oxide of 
zinc. Instead of this a solution of peroxide of hydrogen 
may be dabbed on. The scraping is to be repeated two to 
three times a week. The procedure seems rough, but after 
the first scraping the patients do not mind it much, and the 
result is the attainment of a smooth skin in a much shorter 
time than by any other method of treatment. With this 
plan we may use a sulphur ointment, a drachm to the 
ounce to be applied twenty-four hours after the scraping, 
or a wash of bichloride of mercury, one-half grain to the 
ounce of dilute alcohol, to which may be added a little 
glycerin. Thus will we fulfill all three of the indications 
for treatment. 

The same results can be attained in a slower way by 
opening every pustule with an acne lancet (Fig. 8) and 
squeezing out every comedo. This is to be done once or 
twice a week and a sulphur preparation used between 
times. Very timid patients who will allow no surgical 
interference may be treated according to the same princi- 
ples by directing them to scrub their faces thoroughly 
once a day with green soap, or tincture of green soap, and 
leave the lather on. After a day or two of good scrubbing 
an amount of dermatitis will be excited sufficient to cause 
the old skin to peel oif, while the tops of many of the 
lesions will have been torn off and the skin will have been 
decidedly stimulated. Not until the skin has become 



76 DISEASES OF THE SKIN. 

scaly and feels tense to the patient should a soothing oint- 
ment be applied. Repeated applications of the soap fric- 



FlG 




Fox's acne lance and dermal curette. 

tions will slowly bring about improvement. Rubbing the 
face with fine sand or coarse cornmeal will do good, but 
is not so elegant. 

Massage to the skin will give nearly if not quite as 
good results as the rougher curettage. The tips of the 
fingers should be dipped in cold cream, and then, pressure 
being exerted by them, the skin of the forehead should be 
deeply stroked from the middle line out and over the tem- 
ples. The nose should be stroked from the bridge out- 
ward and downward. The skin of the cheeks should be 
pinched up and rolled between the fingers and thumb. 
These movements facilitate the emptying of the follicles. 
The application of the galvanic current by means of the 
roller electrode, or by ordinary sponge electrodes, will in 
some sluggish cases prove helpful. 

A vast number of prescriptions have been written which 
are " good for acne," the majority of which contain sul- 
phur in some form, and in the strength of half a drachm 
to one drachm to the ounce, and in ointment or lotion 
form. Sulphur in powder form is good if the patient 
doesn't mind the odor. The ordinary sulphur ointment 
of the Pharmacopoeia diluted one-third or one-half is as 
good a preparation as any. It may be made more elegant 
by adding some perfume. The sulphuret of potassium 
may be used in the following : 

R. Potass, sulphurat. , \ r - ►,. or 

Zinci sulphat. , J ° 1 ' ' i 

Aquse rosee, §iv; 100J M. 

This preparation is commonly spoken of as "Lotio alba" 



ACNE. 77 

and is one of the most useful of the compounds of sulphur. 
It is to be applied every day after being well shaken. 

Vleminckx's solution is an active preparation in caus- 
ing the old skin to exfoliate. It is composed of — 

R. Calcis, Sss; 151 

Sulph. sublim., 5J; 30] 

Aquae destil., gx; 300| M. 

Cook to gyj and filter. 

After this has been left on a few horn's it must be washed 
off and a soothing ointment, such as ungt. zinci oxid. or 
ungt. aquae rosse, applied. It is most useful in acne of the 
back. 

Mercurial preparations may be used to more advantage 
in some cases than those of sulphur. It must be borne in 
mind that a mercurial must never be applied to the skin 
until all traces of sulphur are removed, or vice versa, be- 
cause if the precaution is forgotten the black sulphide of 
mercury will be formed, which will give the skin the ap- 
pearance of being sown with powder grains. A lotion of 
corrosive sublimate, 1 in 1,000 to 2,000, may be mopped 
on once or twice a day, or an ointment of the protiodide, 
as recommended by Duhring, may be used : 

R. Hydrarg. protiodid., 
Hydrarg. ammon., 
Ungt. simplicis, gj; 30 M. 

Lassar * recommends the following paste : 

R . /3-naphtol, 10 parts. 

Sulphur precip., 50 " 

Vaseline, ") __ „_ u , T 

Sapo viridis, } aa 2o M ' 

This is to be spread upon the skin to the thickness of 
the back of a knife-blade, and left on for fifteen or twenty 
minutes. It is then to be wiped off with a soft cloth, and 
the skin powdered with talc. The skin becomes inflamed, 
turns brown and peels off. The application is to be re- 
iTherap. Monatshft., 1887, Xo. 1. 



gr. 


v-xv; 


1 


gr. 


x-xxx; 


2 


SJ 




30 



78 DISEASES OF THE SKIN. 

peated every day until the skin does peel off. Des- 
quamation can be hastened by the application of Lassar's 
paste with two per cent, of salicylic acid. 

Resorcin has been commended, used in twenty per cent, 
strength. Ichthyol, the ammonio-sulphate, is recom- 
mended by Unna for acne, either as a three to five per 
cent, ointment or a three to ten per cent, aqueous so- 
lution. As much as fifteen grains of it is to be taken by 
the mouth during the day. A mild corrosive sublimate 
wash is to be applied to the face until the patient goes to 
bed, and then a ten per cent, aqueous solution, or paste of 
ichthyol, is to be kept on till morning. Startin * has em- 
ployed local steam baths, by means of a steam atomizer, 
with success. The steaming should be kept up for twenty 
or thirty minutes, and tincture of benzoin used in the medi- 
cine cup. While useful in some cases it does harm in 
other cases. 

One of the most useful preparations in acne is one pro- 
posed by Unna composed of 



R . Lanolin, 30 

Ac. acetici vel \ \ oo 
Ac. acetici dil. , j 

Adepis benzoat. , 30 

Sulphur precip. , 10 



M. 



This is to be applied at night, and when possible in the morning. 

The foregoing remedies are all specially adapted to 
more or less sluggish cases, the type met with in the 
great majority of instances. In very recent and quite 
inflammatory cases, besides the administration of laxa- 
tives and the regulation of the diet, the patient should 
be directed to bathe the face in hot water either with or 
without the addition of borax (3ij to Oj), and apply a 
soothing ointment. 

Bathing of the face with hot water before the appli- 
cation of any lotion or ointment should be advised. In 
indurated acne, where cutaneous abscesses have formed 
1 Lancet, 1889, i., 934. 



ACNE. 79 

and the lesions are discrete, each abscess will have to be 
opened up with a lancet, the contents of the abscess dis- 
charged, and carbolic acid, either pure or diluted, intro- 
duced, by means of a little cotton around the end of a bit 
of wood, into the abscess cavity, so as to destroy the lining 
membrane. 

Individual acne lesions can sometimes be aborted by 
touching them with pure carbolic acid, or acid nitrate of 
mercury. 

To obtain the best results in acne the physician must 
treat each case himself, opening the pustules and squeezing 
out the comedoes twice a week at first, less often later. 
If at the same time he will strive to improve the general 
condition of the patient and use the acetic acid paste 
given above he will succeed in greatly benefiting his 
patient. 

Prognosis. By persistent effort, and careful regula- 
tion of all the bodily functions, a great improvement can 
be effected, one fairly deserving the name of cure. But it 
is often hard to prevent the occasional appearance of a 
few acne lesions until the period of life in which acne 
usually occurs is passed. There are some rare cases in 
which we can do nothing, because we are unable to remove 
the underlying cause. 

Acne Adenoid. See Lupus Miliaris. 

Acne Albida. See Milium. 

Acne Artificialis. By this term is meant an inflamma- 
tion of the sebaceous glands and hair follicles caused by 
drugs either applied locally or acting from within. It has 
three principal varieties, namely, tar acne, bromic acne 
and iodic acne, and should be regarded rather as a derma- 
titis medicamentosa than as an acne. Tar produces acne- 
like lesions with black points when applied locally to 
some susceptible skins. As a rule, papules are more 
abundant than pustules, but abscesses and furuncles may 
form. These lesions are not confined to the usual locations 
for acne, are particularly abundant ,on the extensor sur- 



80 DISEASES OF THE SKIN. 

face of the arms, and are recognizable by their central 
black points, and by the fact that the patient is using tar. 
For its cure all that is necessary is to stop the use of the 
tar and to soothe the inflamed skin. None of these acnes 
is a true acne. Bromic and iodic acne will be spoken of 
under drug eruptions. Derivatives of tar, chrysarobin 
and pyrogallol may also produce similar acne-like lesions 
when applied externally. 

Acne Atrophica is a term applied to the scars left by 
acne, and to acne frontalis. The first needs no descrip- 
tion. The other will be found further on. 

Acne Cachecticorum is rather to be regarded as a scrof- 
uloclerm than an acne, as it probably has little to do with 
the sebaceous glands. It occurs in broken-down or scrof- 
ulous subjects, and is particularly prone to appear upon 
the extremities, though it may be disseminated over the 
whole body. It takes the form of small, congested or 
dark-red, sluggish flat papules and papulo-pustules that 
run a slow course, break down, perhaps ulcerate and leave 
small depressed cicatrices. Occurring on the fingers, 
these will often be congested and clubbed. The lesions 
may appear in crops. It occurs in children as well as in 
adults. It is one of the rare forms of the disease, and 
requires tonic remedies such as cod-liver oil and iron for 
its cure. 

Acne Cornea. See Keratosis follicularis. 

Acne Fluente. See Seborrhoea oleosa. 

Acne Frontalis. Synonyms : Acne rodens, a. ulcereuse, 
a. atrophique, a. arthritique, a. miliaire scrofuleuse, a. 
varioliformis of the Germans, a. necrotica, a. pilaris, lu- 
poid acne. 

Acne frontalis is the name given by Boeck to an acne- 
form lesion that occurs in adults on the forehead along 
the line of the hair. It is also met with on the cheeks 
and nose, and some lesions may be on the scalp. It has 
been described as occurring upon the trunk, sternal re- 
gion and back. The eruption consists of pinhead- to 



ACNE. 81 

lentil-sized, reddish-brown, hard papules, on which form 
flaccid pustules that soon dry into a brown crust. If on 
hairy regions, the crust may be pierced by a hair. Some 
papules have an inflammatory halo around them. The 
crust adheres very closely and seems as if sunk into the 
papule. . If removed, a loss of substance is revealed. It 
is possible to press out a drop of pus from under old 
lesions just about ripe enough to lose their crusts. When 
the crust falls of itself it leaves a brownish-red cicatrix 
that gradually grows white. Sometimes the lesions are 
present in large numbers, and as each one runs a slow 
course, lesions in all stages of development will be found. 

This is a rare form of disease, and its etiology and pa- 
thology are still undetermined. It bears a decided resem- 
blance to syphilis in some of its forms. It is probable 
that some of the cases that have yielded to mercurial oint- 
ments were syphilitic. It runs a very chronic course, 
sometimes lasting for years. 

Treatment. In treatment a sulphur, resorcin, or 
mercurial ointment will probably give the best results. 
The ointment of the ammoniate of mercury is one of the 
best. Curetting is also of great service. 

Acne Hypertrophica. See Rosacea. 
Acne Iodic and Bromic. See Dermatitis medicamentosa. 
Acne Keloid. See Dermatitis papillaris capillitii. 
Acne Medicamentosa. See Acne iodic and bromic. 
Acne Mentagra. See Sycosis. 
Acne Miliaris. See Milium. 
Acne Necrotica. See Acne frontalis. 
Acne Pilaris. See Acne frontalis. 
Acne Rodens. See Acne frontalis. 
Acne Rosacea. See Rosacea. 
Acne Scrofulosorum. See Acne cachecticorum. 
Acne Sebacea. See Seborrhoea. 
6 



82 DISEASES OF THE SKIN. 

Acne Syphilitica. See Pustular syphiloderm. 

Acne Tuberculoids See Molluscum contagiosum. 

Acne TJlcereuse. See Acne frontalis. 

Acne Varioliformis. See Molluscum contagiosum and 
Acne frontalis. 

Acnitis. See Hidradenitis suppurativa. 

Acrochordon (A 2 k-ro-ko 2 rd'-o 2 n). See Fibroma. The 
term is also applied to large or small polypoid promi- 
nences produced by an overgrowth of the endothelium of 
the sebaceous glands. These occur in elderly people upon 
the eyelids and neck. They may attain the size of hazle- 
nuts and look like overgrown milia. The treatment con- 
sists in removing them by ligature or scissors. 

Acrodermitite. Under this name some French writers 
describe an eruption that bears a strong resemblance to 
impetigo contagiosa, if it is not the same disease. 

Acrodynia (A 2 k-ro-di 2 n r -i 2 -a 3 ) is a disease closely allied 
to pellagra in its symptoms, that has been observed chiefly 
amongst the French and Belgian soldiers, and is probably 
due to some defect in food supplies. It begins with gastro- 
intestinal irritation, to which certain neuroses soon add 
themselves, such as formication, hyperesthesia and anaes- 
thesia. An erythema of the hands and feet, and may be 
of the whole body, followed by brown or black pigmenta- 
tion, is the cutaneous element of the disease. Recovery 
usually takes place, though death may occur from diarrhoea. 

Acromegaly (A 2 k-ro r me 2 g-a 2 l-i 2 ). A disease character- 
ized by overgrowth of the bones and soft tissues of the 
face, hands, wrists, and feet. It is a rare condition and is 
allied to elephantiasis. It is a progressive and, usually, 
symmetrical disease and at times attains immense propor- 
tions. The skin becomes dry and harsh, yellowish and 
wrinkled. Fibromata may develop. Symptoms of nerv- 
ous derangement are also present. The cause is un- 
known and treatment of no avail. 

Actinomycosis (A^-tPn-o-mi-ko'sPs). While this is 



ADENOMA. 83 

usually a disease of cattle, in which it causes tumors of 
the jaws, it may attack man and produce nodular tumors 
with fistulous openings. It is due to the invasion of the 
tissues by the ray fungus. Infection usually occurs by 
the mouth along a carious tooth, but it may take place 
through the digestive tract, the lungs, and, rarely, by an 
abrasion of the skin. The incubation period is about four 
weeks. The tumors bear a strong resemblance to sarcoma 
and are livid or bluish-red. At first firm, they, after a 
time, soften and break down and discharge through a fis- 
tulous tract, at first a purulent, afterward a sanious 
material, in which are numerous yellow granules, from 
pinhead to hemp-seed size. It runs a chronic course. Its 
prognosis is bad. Iodide of potassium in 10- to 15-grain 
doses three times a day is well spoken of by M. Morris, 1 
and may be combined with the insertion into the sinuses 
of a one per cent, solution of the same drug. If this fails 
surgical procedures may be resorted to. 

Addison's Keloid. See Morphcea. 

Adeno-carcinoma is a carcinoma originating in the 
glands of the skin, most often in the sweat glands. 

Adenoma (A 2 d-e 2 n-o r ma 3 ). These are glandular tumors, 
and are due to a proliferation of the lining cells of either 
the sebaceous or sweat glands. There are, therefore, two 
varieties : A. sebaceum and A. sudoriferum. Though 
met with in persons of mature years, it is not improbable 
that they are congenital defects. They form solid tumors 
from pinhead to egg size or larger. They may remain 
stationary or grow ; may disappear spontaneously, ulcerate, 
form cysts, or undergo hyaline, colloid or fatty degenera- 
tion. While usually benign, they may become malignant. 
They tend to relapse after extirpation. 

The sebaceous form is encountered most often on the 

face, about the nose and mouth ; less frequently upon the 

scalp, but may occur anywhere. Their color varies from 

pale yellow to red, when they will have fine telangiectases 

1 Lancet, 1896, 1, 1553. 



84 DISEASES OF THE SKIN. 

over them. They occur most often in females, are gen- 
erally multiple, often with an uneven surface, and seated 
deep in the skin. Pollitzer has cured one case of the se- 
baceous variety by means of multiple scarifications. 

The sudoriferous variety occurs as dirty grayish-white 
tumors, sometimes in groups, with uneven, often knobby 
surface. They are rare lesions of the skin, difficult of 
diagnosis, and require extirpation or total destruction for 
their cure. 

Ainhum is a disease most frequently seen in the negro 
race, though a number of cases have been reported from 
India. It is seen in men more often than women, and 
several members of the same family have been known to 
be affected by it. The little toe, of one or both feet, is 
the one usually diseased, though the other toes do not al- 
ways escape. It begins as a furrow on the inner and 
lower side of the proximal end of the toe, which gradu- 
ally extends outward and upward so as to encircle the 
whole toe at its juncture with the foot. In the meantime 
the toe becomes enlarged, separates from its next neighbor, 
and rotates outward. When fully developed the toe 
wobbles about so that it interferes with walking. The 
whole process is unattended with ulceration, except acci- 
dentally caused and after the disease has lasted a long 
time. When it sets in the toe falls off. There is little 
pain experienced till near the end of the disease. It 
takes from one to ten years for the full development of 
the disease. The cause is unknown. The process is one 
of progressive degeneration and destruction of all the ele- 
ments of the toe — skin, muscles, bone. Amputation is re- 
quired for the cure, and healing takes place rapidly. 

Albinism. See Leucoderma. 

Aleppo Boil, Aleppo bouton, or Aleppo evil, is an ill-de- 
fined furuncular disease occurring in Syria and the Le- 
vant, where it is endemic and widespread. One or more 
pea- or bean-sized pustules appear that slowly grow and 
ulcerate indolently. The extremities and face are the 



ALOPECIA ADNATA. 85 

parts most often affected. All ages and conditions con- 
tract the disease. One attack usually protects against 
subsequent infection. 

Algidite Progressive. See Sclerema neonatorum. 

Algor Progressivus. See Sclerema neonatorum. 

Alopecia (A 2 l-o-pe r shi 2 -a 3 ), Synonyms : Calvities ; (Fr.) 
Alopecie ; (Ger.) Kahlheit ; (Ital.) Calvezza ; (Sp.) Cal- 
vez ; Baldness. 

By alopecia is meant a partial or general loss of the 
hair, so as to produce a noticeable thinning or a bare spot. 
There are four main varieties, namely : Alopecia adnata ; 
Alopecia senilis ; Alopecia prematura, or presenilis ; and 
Alopecia areata. 

Alopecia Adnata is congenital baldness, and is a rare 
affection. 

Symptoms. The newborn child is covered with long 
dark hair which soon falls to give place to fine lanugo 
hairs ; or this change has taken place before birth, the 
usual course of events, and at birth lanugo hairs only are 
present. In alopecia adnata there is not the slightest 
trace even of lanugo hairs either on the scalp or eyebrows. 
In some cases the baldness is not so complete. Most 
cases, after months or years, recover either altogether or 
partially, but in some cases the hair never grows. In 
pronounced cases delayed dentition or deficiency of the 
teeth has been observed. 

Etiology. The cause of the disease is arrest of the 
development of the hair, probably due to an error in in- 
nervation. It is said to be hereditary in some families. 

Pathology. There is a complete absence both of hair 
and hair papillae. There are some abortive hair follicles. 
Otherwise the scalp is normal. 

Treatment. The treatment is mainly an expectant 
one. The nutrition of the child should be looked after 
and the scalp kept in a healthy condition. If this expect- 
ant plan does not satisfy the child's attendants, some of 



86 DISEASES OF THE SKIN. 

the stimulating hair washes, as in alopecia presenilis, may 
be prescribed for the moral effect upon them. 

Alopecia Senilis is baldness occurring in advancing 
years. Any loss of hair commencing about the forty-fifth 
year and without any apparent cause may be placed under 
this heading. Graying of the hair may have preceded it 
for several years or may be coincident with it. Or the 
hair may fall without becoming gray. The hair fall 
having once begun is progressive, though its rate of prog- 
ress may be slow or fast. It usually shows itself first 
upon the vertex of the head, forming the tonsure, which 
slowly increases in size and, moving forward, renders the 
whole top of the head bald. Or it may begin anteriorly 
and move backward. Or the hair on the whole top of the 
head may become thinned at once. Rarely are the tem- 
poral and occipital regions bald, and an island or tuft of 
hair is sometimes preserved for a long time in the middle 
frontal region. The hair fall is always symmetrical and 
the bare scalp is smooth, oily, shiny and appears as if 
stretched. Not only does the hair fall from the scalp, but 
it may fall from the axilla? and pubic region ; these mani- 
festations I believe to be more common in women than 
men. Very rarely does the beard fall. 

Etiology. The cause of this form of baldness is a 
progressive atrophy of the scalp. Men are far more prone 
to the disease than are women. 

Treatment. As to the treatment we can do nothing. 
Prophylaxis, as described under Alopecia prematura, will 
delay its onset. 

Alopecia Prematura is baldness occurring before middle 
life. It may be idiopathic or symptomatic. 

Alopecia prematura idiopathica arises without any evi- 
dent disease of the scalp or disorder of the general health. 
It usually begins in early life, between twenty-five and 
thirty-five ; it may begin as early as the eighteenth year. 
Its general course is the same as the senile form of alopecia. 
Very often the upper parts of the temples are earliest 



ALOPECIA. 87 

affected, the hair line receding. In those who part the 
hair in the middle, the thinning of the hair about the part 
may be the first thing to attrac attention. The process 
of the hair fall is one of progressive thinning of the indi- 
vidual hairs at first, and then of the whole quantity of 
hair, so that strong hairs give place to lanugo hairs, and 
these in turn fall and leave bald places. At the same 
time a progressive tightening of the scalp upon the skull 
will be observable in some cases, the scalp having lost 
that cushion of fat that is under it in early life. The hair 
fall having begun is progressive, though years may elapse 
before there is absolute baldness. The tonsure may not 
enlarge for a long time, and then increase rapidly in size. 

Etiology. The main cause of this form of baldness 
is heredity. Fathers and sons for generations may grow 
bald early, or the inherited peculiarity may have to be 
traced to the grandparents or some collateral line. Not 
all the children of one family in which baldness is 
hereditary are bald, but it will manifest itself in two or 
three of the children. According to Pincus, l inheritance 
and chronic eczema or an impetiginous eruption on the 
scalp in the years preceding puberty are the only predis- 
posing causes of baldness. Insufficient or improper care 
of the scalp ; daily sousing of the hair with water, com- 
bined with improper drying of the hair afterward ; sweat- 
ing of the head, either spontaneously or on account of the 
wearing of unventilated or hot head-coverings ; constant 
mental strain, either on account of intellectual work or of 
worry ; the wearing of stiff, unyielding hats ; gout ; and 
dissipation, are all put forth by reputable observers as 
causes of premature baldness. 

That women are less often bald than men probably de- 
pends upon several factors : The fatty cushion beneath 
their scalps is longer preserved than in men ; they give 
more attention to the care of the hair and less often wet 
it ; and their hats are soft, ventilated and fit loosely. 

Teeatmext. \Ye can do more for this form of bald- 
1 Virchow's Archiv, 1867, ^li., 322. 



88 DISEASES OF THE SKIN. 

ness by prophylaxis than by attempts at making the hair 
that has fallen ont grow in again. Prophylaxis should 
begin at the beginning of life, and should be continuous. 
This is of special importance in the case of children in 
families prone to early loss of hair. 

The hygiene of the scalp is the chief part of thcprophy- 
lactic treatment. Beginning at infancy, the scalp should 
be gently cleansed of the vernix caseosa and other extra- 
neous substances that have gathered on it during the pro- 
cess of parturition. This should be done by the gentle use 
of soap and water after rubbing in a little sweet almond 
or other bland oil. No force should be used, and after the 
scalp is washed it should be patted dry with a soft, warm 
cloth, and a little oil or vaseline smeared over it. After 
the first washing it should be oiled daily and washed 
every second day. When the' hair begins to grow, a soft 
brush alone should be used to arrange it, and the daily 
oiling may be stopped unless sebaceous matter accu- 
mulates in cakes, in which event the oiling should be 
continued. Sometimes it is well to add a little sulphur 
to the oil or vaseline, but in most cases it is unnecessary. 
The slightest indication of disease of the scalp should be 
promptly and properly dealt with. A child's hair should 
be cut short, not cropped close to the head. After a girl 
has reached her eighth or ninth year the hair should be 
allowed to grow. 

The hair and scalp do not need to be washed more than 
once in two or three weeks, and for this purpose any good 
soap will do, with plenty of water to wash out the soap- 
suds. Borax with water will clean the scalp nicely, but 
its continuous use is injurious. The yolk of three eggs 
beaten up with lime-water makes an elegant shampoo. 
The daily sousing of the head in water should be pro- 
hibited. Deep brushing of the hair with a long-bristled 
brush of sufficient stiffness to warm, but not scratch, the 
scalp is one of the best agents we have for stimulating 
the scalp. The brushing should be done daily and sys- 
tematically. 



ALOPECIA. 89 

Pomades and hair washes should be avoided unless 
there is some evident disease of the scalp. Women 
should be cautioned against pulling their hair into arti- 
ficial and constrained positions. It is most important that 
a sufficient amount of outdoor exercise should be taken 
to aid in keeping the patient in good general condition. 

When the hair has begun to fall it is important that the 
hvgiene of the scalp should be begun, if not already prac- 
tised. We can do more for our cases in this way than by 
any other method. 

Many remedies have been advised for the curative treat- 
ment of baldness. Pilocarpine, in hypodermic injections 
or in ointment form, has been warmly commended. Las- 
sar l prescribes it as follows : 

R. Hydrochlorate of pilocarpine, gr. xxx; . 2| 

Vaseline, 5 Y ! 20 

Lanolin, §ij; 60 j 

Oil of lavender, gtt. xxy. M. 

He also advises oil of turpentine, equal parts with an 
indifferent oil or alcohol. It is my experience that most 
of these cases do better with oily than with alcoholic prep- 
arations. Gallic acid, 3 per cent., in an oily excipient ; 
tar ; galvanism ; massage ; tincture of cantharides (5j— 5j); 
tincture of mix vomica (5j— oj), and a lot of other irritants 
and essential oils have their advocates. My experience 
teaches me that so-called " hair tonics " are of little value 
and that the best remedies are attention to the general 
health of the patient, massage to the scalp, and daily, sys- 
tematic and deep brushing of the hair. Pilocarpine is the 
only drug that has shown any decided influence on hair 
growth. 

Prognosis. The prognosis of this form of baldness is 
bad and especially so if the disease is hereditary and the 
patient is more than thirty years of age. It is better with 
women than with men, as they will give more time to the 
care of their scalps and show less tendency to alopecia. 

iTherap. Monatsheft, 1888,, Xo. 12. 



90 DISEASES OF THE SKIN. 

Alopecia prematura symptomatica is premature baldness 
in which there is some evident disease of the scalp or 
disorder of the general nutrition of the body to account 
for it. It has four varieties : Alopecia furfuracea seu 
pityrodes, A. syphilitica, Denuvium capillorum and A. 
follicularis. 

Alopecia Furfuracea seu Pityrodes is the form most fre- 
quently met with and the one in which we can often obtain 
good results by treatment. In my experience seventy per 
cent, of all cases of loss of hair are of this variety. 

Symptoms. In it Ave have an evident disease of the 
scalp to deal with — that is dandruff. By this we mean 
either a seborrhoea with fatty crusts, or else a pityriasis 
with more or less abundant scaling. Both these condi- 
tions are now regarded as different forms of eczema sebor- 
rhoicum. 

Alopecia pityrodes has two stages : The first one lasts 
from two to seven years or more and is attended by a 
greater or less amount of dandruff and by dryness of the 
hair. Then comes the second stage, when the hair falls 
more or less rapidly. Its course may be the same as that 
of the two previously described forms of baldness, though 
more commonly the whole top of the head is affected at 
once, the hair becoming progressively thinner in diameter 
and less in amount until baldness results. As the baldness 
increases the dandruff lessens. The disease is one of early 
life in a large number of cases, often occurring between 
the twentieth and thirtieth year, and affects both sexes. 

Etiology. The cause of the hair fall is the dandruff. 
By this it is not meant that everyone who has dandruff 
will become bald. Everyone's experience is against that. 
But it is true that in certain persons when, on account of 
some error in the nutrition of the sebaceous glands, they 
become diseased, the hair follicles sympathize with them 
and after a time the hair production ceases. Of late the 
opinion is gaining ground that alopecia pityrodes is con- 
tagious, and the experiments of Lassar and Bishop 1 would 
1 Monatshefte f. prakt. Dermat., 1882, i., 131. 



ALOPECIA. 91 

seem to prove this. They succeeded in producing typical 
alopecia pityrodes in guinea pigs by rubbing into their 
backs a pomade composed of the scales taken from the 
head of a student who was afflicted with the same disease. 
A number of observers have reported from time to time 
the finding of a parasite in this disease, but as yet no one 
micro-organism can be demonstrated as positively at the 
bottom of the trouble. Sabouraud l believes that the same 
parasite that produces the seborrhoea produces the loss of 
hair. It is a micro-bacillns that grows down the hair fol- 
licle between its wall and the hair and causes atrophy of 
the hair papilla. 

Teeatmext. The treatment of this form of baldness 
must be addressed to the cure of the seborrhoea or pityria- 
sis that causes the loss of hair. Prophylaxis is here again 
more important than the use of remedies for promoting the 
growth of the hair. The treatment of seborrhoea and pity- 
riasis will be considered under their respective headings 
and need not be here detailed. My belief is that greasy ap- 
plications are better than those containing alcohol. The 
mistake is frequently made of prescribing tincture of 
cantharides or other irritant because the hair foils. Of 
course, these things, in an already more or less inflamed 
scalp, only do harm. If we can succeed in curing the 
seborrhoea, the hair will take care of itself. If the case 
comes to us before absolute baldness is established we can 
feel pretty confident that we can stop, or at least delay, 
the fall of the hair. But we must inform our patients 
that it is only by long and persistent treatment that we 
can accomplish anything. 

Lassar's plan of treatment has gained great currency, 
and is as follows : The scalp is to be vigorously washed 
each day with a tar soap that forms plenty of suds. The 
soapsuds are to be washed out with warm, followed by 
cold, water, the scalp dried and anointed with equal 
parts of a half per cent, solution of bichloride of mercury 
in glycerin and cologne water. This is to be dried out by 
^Innal. de derm, et sypli., 1897, viii., 257. 



92 DISEASES OF THE SKIN. 

applying a half per cent, solution of /3-naphtol in absolute 
alcohol. Finally, an oil made up of 



R . Ac. salicylici, 3iv ; 16 

Tincture of benzoin, gr. xl ; 3 

Neat's-foot oil, §iij ; 100 



M. 



is to be applied. The procedure is to be kept up for six 
to eight weeks. I have found few patients who would 
persist in it, and in these I have seen little good result. 
For women it is impracticable. 

Resorcin has been commended. It may be prescribed 
as follows : 

R . Resorcin pura, gr. xv ; 3 

01. ricini, gss ; 6 

Spts. vini rect., ad ,^i ; 100 

M. 

Sabouraud recommends the use of a pomade containing 
sulphur, oil of cade and yellow oxide of mercury on three 
evenings of the week, and on the following mornings to 
wash the scalp with soap and water, and rub with a brush 
charged with a two per cent, solution of resorcin in equal 
parts of alcohol and ether. 

Tar is a good remedy, but it is objectionable on ac- 
count of its odor and color. /2-naphtol, in 5 to 10 per 
cent, strength, and hydrate of chloral in about the same 
strength, may be tried. Sulphur is the most reliable 
remedy. Its efficacy is increased by the addition of two 
grains of the muriate of pilocarpine to the ounce of a 
ten per cent, sulphur ointment made with unguentum 
aquae rosse or cold cream. Further particulars in regard 
to the treatment of the seborrhoea will be found under the 
section upon that subject. When there is absolute bald- 
ness it is questionable if anything will make the hair grow. 

Alopecia Syphilitica may be an early or late manifesta- 
tion of syphilis ; it occurs both in benign and malignant 
cases, and manifests itself as a more or less general and 
temporary hair fall, or as a localized, destructive, and per- 
manent one. 

Symptoms. The former variety occurs early in the 



ALOPECIA. 93 

The variety called Defluvium Capillorum is that sudden 
disease, and is a thinning of the hair in irregularly 
shaped patches scattered over the scalp, giving to it an 
appearance similar to what would be produced by cutting 
the hair carelessly with a dull pair of shears. In rare 
cases we may have a general loss of hair from all hairy 
regions. The broken arch of the eyebrow is always sug- 
gestive of syphilis. There may be some seborrhoea with 
this form of alopecia. 

Localized baldness is one of the later manifestations of 
syphilis and is always preceded by a destructive disease 
of the scalp. The bald spots will vary in size with the 
extent of the destructive process, which may be one of 
absorption or ulceration. 

Diagnosis. The diagnosis of syphilitic alopecia is 
made by observing the irregular shape of the patches and 
that they are not completely bald, and by the occurrence 
of the broken arch of the eyebrow. These should arouse 
suspicion, when other symptoms of the disease will be 
found. It most resembles alopecia areata, but in this dis- 
ease the patches are perfectly circular or oval and entirelv 
bald. 

The baldness due to destructive forms of syphilis can 
be confounded only with that of favus. In the latter dis- 
ease the scalp preserves a reddish color for a long time, 
and then assumes an atrophic, smooth, cicatricial look, 
which is characteristic of it. The history of the two 
eases is very different, as in favus we do not have ulcer- 
ation, and we do have cupped, sulphur-yellow crusts. 
Favus is also more widespread and disseminated than is 
late syphilis of the scalp. 

Treatment. The treatment of this form of baldness 
is that of the underlying disease. A mercurial ointment 
or an oil containing the bichloride may aid in hastening 
the new groAvth of the hair in the early form of baldness. 
The late form may be lessened by active constitutional 
and local treatment, according to the general principles 
laid down for the management of syphilis. 



94 



DISEASES OF THE SKIN. 



and general fall and manifest thinning of the hair which 
comes on during or after some severe illness, such as par- 
turition, fevers, mercurialism and various cachexia?. 

Symptoms. Rarely does it produce complete baldness. 
The fall is usually rapid and takes place during convales- 
cence or after recovery, rather than during the course of 
the disease. Seborrhoea may or may not be present. 

Etiology. The cause of the hair fall is the profound 
disturbance of the nutrition of the body, in which the hair 
sympathizes. 

Treatment. The treatment is rather to be addressed 
to the patient than to the hair. If we can succeed in 
building up the patient's strength the hair will take care of 
itself. The scalp should not be shaved. Local treatment 
is the same as in alopecia pityrodes. 

Alopecia Follicularis is baldness due to some disease of 
the scalp that either destroys the hair follicles or impairs 
the proper performance of their function. A history of 
the causative disease may be obtained, or the disease itself 
will be present. Impetigo; long-continued sycosis; inflam- 
matory diseases, such as erysipelas ; parasitic diseases, such 
as favus and ringworm, and destructive neAV growths, such 
as syphilis and lupus, all may cause alopecia follicularis. 

The etiology, diagnosis, prognosis, and treatment of this 
form of baldness are the same as the disease that gives rise 
to it, for which we must refer to the proper sections. , 

Alopecia Areata. Synonyms : Area celsi ; Area occi- 
dentalis diffluens, seu serpens, seu tyria ; Alopecia circum- 
scripta ; Porrigo seu tinea decalvans ; Vitiligo capitis ; 
Ophiasis ; Phyto-alopecia ; (Fr.) Teigne pelade ; Pelade ; 
(Ger.) Die kreisfleckige Kahlheit ; circumscribed baldness. 

This form of baldness usually begins suddenly, the pa- 
tient discovering by accident, or being told by someone, 
that he has a bald spot. Sometimes, on waking in the 
morning, the patient is astonished ,to find loose hairs in 
his bed, and/ on looking in the glass, to see that he has a 
bald patch" on his head. In some cases the hair fall may 



ALOPECIA. 



95 



have been preceded for days or weeks by neuralgic pains 
in the head. In most people there are no premonitory 
symptoms, and, apart from the bald spots, no discomfort 
on the part of the patient, nor cutaneous lesions. The 
neuralgia may continue after the hair fall or it may cease. 
There may be but one bald patch or there may be a dozen 
patches. A patch may be as small as a three-cent silver 
piece or as large as a silver dollar. If larger — and the 
whole head may be completely bereft of hair — the patch 
is formed by the coalescence of several smaller ones. A 



Fig. 9. 




Alopecia areata. 

patch may attain its full size at once or it may slowly en- 
large, spreading at the periphery. The patches are more 
or less perfectly oval or circular in shape and sharply de- 
fined against the surrounding hair. Patches formed by 
the coalescence of other patches lose the oval outline and 
may have a scalloped border. The color is usually that 
of the normal scalp ; it may be pale or hypersemic. The 
patch is perfectly bare and smooth, without scales, as a rule. 
Sometimes it is dotted over with short, broken hairs, old 
roots that soon fall out. Sometimes it looks as if it were 



96 DISEASES OF THE SKIN. 

depressed, an appearance due to falling out of the hair 
roots. Any or all the hairy regions of the body may be 
affected, the patient sometimes being entirely denuded of 
hair. Most often it is the scalp that suffers, especially 
the temporal and occipital regions. Around the border 
of a recent patch the hair is loosened so that it may be 
readily extracted. The sensibility of the skin may be 
diminished. Generally it is preserved. 

The course of the disease is chronic, with a strong ten- 
dency to spontaneous recovery in anywhere from three 
months to several years. Recovery is heralded by the 
growth of a fine down upon the bald patch. This will 
fall out and be replaced by lanugo hairs that in their turn 
will fall out to be replaced by stronger hairs, until normal 
hairs will grow at last, though these at first may be white. 
Some cases relapse year after year ; in some cases the hair 
never grows beyond the lanugo stage ; and some cases re- 
main permanently bald. 

Etiology. The subjects of the disease may be in ap- 
parently perfect health, but not infrequently they are of 
very nervous temperament, exhausted by overwork or 
nervous strain, or out of health in some way. Both sexes 
are affected, the male sex rather more than the female. 
It occurs very often in children. Thus Crocker, who has 
a large experience with children, met with it in children 
under twelve years old thirty-seven times out of eighty- 
three cases. The youngest case reported was at two years 
of age, and cases have been seen as late as in the sixtieth 
year. It is rather more frequent among the poor than 
among the well-to-do. It is more frequent in some coun- 
tries than in others. Thus Crocker's tables show that in 
London it forms two per cent, of all skin cases ; Bulkley's 
tables show but a little more than one-half of one per cent, 
in New York. 

The disputed points in the etiology of alopecia areata 
are its contagiousness, and whether it is a neurosis or a 
parasitic disease. At the present time it is impossible to 
decide with absolute certainty which of the contending 



ALOPECIA. 97 

parties is right. Most instances of contagion have been 
reported by French observers whose diagnostic skill we 
can hardly call in question. They have reported instances 
in which a large number of cases have appeared in bar- 
racks or schools, and from there spread to neighboring 
towns. In England similar apparent epidemics have been 
reported, but as a fungus indistinguishable from the 
trichophyton fungus was found in the surrounding hairs 
they were doubtless instances of bald ringworm. It is 
possible that some of the French epidemics were of simi- 
lar character. In this country one epidemic apparently of 
alopecia areata has been reported by Putnam. 1 The cases 
were examined by Drs. J. C. White and J. T. Bowen, of 
Boston, who agreed in the diagnosis. Nothing suggestive 
of trichophytosis was found. Isolated instances of ap- 
parent contagion have been reported by various physicians. 
Certainly the body of experience is against the contagious- 
ness of the disease. Besnier and Doyon, 2 who believe 
firmly that the disease is contagious, think that it is trans- 
mitted most often by means of the barber's utensils, espe- 
cially the patent clippers, and that it is impossible in a 
great number of cases to trace the contagion. Hutchin- 
son and some other English authorities are inclined to the 
belief that in many cases ringworm preceded the appear- 
ance of the bald spots at a greater or less interval. 

As to the parasitic origin of the hair fall, it is not yet 
proven. A goodly number of skilled microscopists have 
described the fungus, but they do not agree amongst them- 
selves, and so we are justified as regarding the question 
as unsettled. 

This leaves only the neurotic theory, and by the ma- 
jority of dermatologists the disease is believed to be a 
tropho-neurosis. It has been known to follow blows or 
injuries to the head, moral or mental shock, operation on 
the neck, and, experimentally, injury to or extirpation of 
the second cervical ganglion in cats. 

^rchiv. Pediat, 1892, ix., 595. 

2 Path, et Trait des Mai. de la Peau: Kaposi. French edition, 
Paris, 1891. 

7 



98 DISEASES OF THE SKIN. 

Pathology. Though hairs taken from the margin of 
an advancing area show atrophic changes, there is noth- 
ing distinctive about such changes. A. R. Robinson 1 
found evidences of inflammation, and some round-cell in- 
filtration confined principally to the perivascular region. 
In recent cases there was a coagulation of lymph in many 
lymphatics, and of fibrin in a few of the large and small 
arteries, with, in old cases, a thickening of their walls. 
In recent cases the hair follicles were either without hair 
or contained a lanugo hair or a hair just about to fall. 
The hair-roots, where present, showed atrophic changes. 
In advanced cases the sebaceous glands were degenerated 
or had entirely disappeared. In the worst cases there was 
complete atrophy of the hair follicles and of the subcu- 
taneous fatty tissue. He also describes the presence of 
various cocci in the lymph spaces of the corium and the 
walls of a few of the vessels, which he regards as the 
cause of the disease. Sabouraud 2 in making his exhaustive 
studies of ringworm, was led to investigate alopecia areata. 
The characteristic hair in the disease has the shape of an 
interrogation point. The upper part is normal and pig- 
mented, while the lower part is atrophied and devoid of 
pigment. He found in the upper third of the diseased 
follicles an ampular swelling which he names the utricle 
peladique. These are filled with compact clusters of 
micro-bacilli, the smallest known. These microbes he 
regards as the probable cause of the disease. They gain 
access to the follicles and set up a reaction, followed by 
atrophy of the hair follicles and papillae. The disease is, 
therefore, one of the follicles and not of the hair. Sabou- 
raud's views have not been generally accepted as yet, nor 
does he regard the case as closed. 

Diagnosis. A typical case of alopecia areata is so pe- 
culiar that there is little danger of mistaking it for any- 
thing else. It differs from trichophytosis capitis in its sud- 
den onset, its perfectly bare, smooth, non-scaly surface, 

1 Monatsliefte f. prakt. Dermat., 1888, vii., 409. 
2 Annal. de derm, et syph., 1896, vi., 253. 



ALOPECIA. 99 

without broken, split and gnawed-off hairs, and in the 
absence of the trichophyton fungus from the hair and 
scales taken from the neighboring parts. In bald ring- 
worm patches, which resemble alopecia areata, the fungus 
will be found in the neighboring hair, or some character- 
istic "stumps" will be found on the scalp. In adults 
ringworm of the scalp is very rare. It differs from, favus 
in the absence of cupped crusts at any time in its course, 
in the scalp not presenting that cicatricial appearance al- 
ways met with in favic baldness, and in complete absence 
of fungus growth. 

The baldness due to syphilis may resemble that of alo- 
pecia areata, but other symptoms of syphilis will be pres- 
ent, and there will never be a history of the formation of 
well-defined oval or circular areas. Lupus erythematosus 
at times affects the scalp and produces circumscribed bald 
areas ; but these are not oval or round, and the skin is red 
and scaly, and evidently cicatrized. The alopecie innom- 
inee of Besnier is extremely difficult to diagnose from alo- 
pecia areata. It differs in not forming regular oval 
or round bald areas, but rather irregular ones, with 
clumps of hair at their borders ; in having a cicatricial 
appearance, and in presenting, at first at least, some evi- 
dences of dermatitis or folliculitis. This type of baldness 
has not yet become well recognized. 

Treatment. In a disease that is essentially self- 
limited it is hard to estimate how much good our reme- 
dies do. One duty we have without peradventure, and 
that is, to look after the general condition of the patient. 
A large number of the cases require a stimulating and 
tonic treatment — iron, quinine, strychnine, arsenic, cod- 
liver oil or hypophosphites. Children should be taken 
out of school and allowed to run free. Our hardest task 
will be to manage those nervous patients who are ever a 
trouble to us. 

As far as local treatment is concerned, it may be summed 
up in two words : patience and stimulation. As many of 
our parasiticides are stimulating to the skin they may be 



100 DISEASES OF THE SKIN. 

used with benefit, whether we believe in the parasitic 
cause of the disease or not. 

The stronger water of ammonia dabbed on to the scalp 
by means of a swab, care being taken to guard the eyes, 
will be beneficial in some cases. It is remarkable how 
little reaction this powerful remedy will cause in alopecia 
areata. Pilocarpine, in hypodermic injections, or in oint- 
ment form, is at times beneficial, combined with sulphur 
ointment and well rubbed in. I have seen the hair come 
back promptly in a few cases and of normal color. 
Painting the scalp with acetic acid until it whitens, and 
then sponging off with cold water, and repeating every 
three or four days ; chrysarobin, fifteen or thirty grains to 
the ounce, well rubbed into the scalp once a day ; carbolic 
acid (95 per cent.) applied every two weeks or so to small 
areas at a time ; the bichloride of mercury, two to four 
grains to the ounce in alcohol, or oleum pini sylvestris ; 
the oleate of mercury, in the strength of 2 to 10 per cent. ; 
blistering with cantharides ; or 33J per cent, of iodine in 
collodion, and galvanism, have one and all been followed 
by the return of the hair. 

Moty 1 reports good results from hypodermic injections 
of bichloride of mercury, injecting five or six drops of an 
aqueous solution (1 : 500) into many places about each 
patch. In a later number of the same journal (p 1 . 864) 
he announced that he then used a 4 per cent, solution of 
the mercury, with a 2 per cent, solution of cocaine ; that 
he made but a single-drop injection in a medium-sized 
patch, and four to five injections about a large patch, and 
at its periphery. Pauses of four days were taken between 
the injections, and a cure is expected after the fourth series. 

Sabouraud 2 advises in single-patch cases cutting the 
hair short, epilating about the patch and rubbing the 
patch every second day with one part of Bidet's vesi- 
cating liquid and three or four parts of chloroform. 

1 Ann. de derm, et sypli., 1891, ii., 406. 

2 Diagnostic et traitement de la pelade et des teignes de 1' enfant. 
Paris, 1895. 



ANESTHESIA. 101 

Every morning the whole scalp is to be nibbed with 



R. Alcohol, camphorat, ^iv ; 125 1 

Spts. terebinthena?, 5 V '■> 25 

Aquas ammonia?, 5J 5 ^ 



M. 



If the patch is very large, instead of the cantharidal 
solution nse 



R. Ac. acetici crystal., gr. i-iij ; .065-. 194 

Chloral., 5 j ; 4 

Ether., gj ; 30 



M. 



From time to time the patch should be shaved as the 
young hairs come in, while the strength and the number 
of applications of the strong solution should be lessened. 
In obstinate cases he applies a blistering fluid at night to 
a limited area, opens it the next morning and paints the 
surface with nitrate of silver solution. The surface is to 
be covered with absorbent cotton. This is to be repeated 
every week. 

It is advisable to pluck the loose hair from around the 
patch for a zone of perhaps an eighth or a quarter of an 
inch. Every few days slight traction is to be made on 
the hairs surrounding the patch and all the loose ones 
pulled. Massage is also useful. 

Peognosis. Even if left to itself the chances are that 
the hair will grow in again. This good prognosis should 
be guarded when the patient is past middle life and in 
those malignant cases in which there is complete baldness 
that has lasted several years. 

Alopecia Circumscripta. See A. areata. 

Alopecie Innominee. See Folliculitus decalvans. 

Alphos. See Psoriasis. 

Anaesthesia (Am-eVthe'zP-a 3 ) is a loss of sensation in 
the skin which occurs in a number of diseases of the nerv- 
ous system, notably in hysterical affections. It may be 
general or partial, or affect but one-half of the body. 
There may be loss of sensibility to pain while the tactile 
sense is preserved (analgesia), or intense pain with loss 
of ordinary sensibility (cuuesthesia dolorosa). There are 



102 



DISEASES OF THE SKIN. 



many substances which, locally applied, will cause anaes- 
thesia, such as carbolic acid, cocaine, aconite ; and many 
others which will abolish sensation when taken internally. 
The subject belongs to the domain of the neurologist. 

Anatomical Tubercle. See Tuberculosis verrucosa cutis. 

Angio-keratoma l (An 2 -gi-o-ker 2 -a 2 t-o r ma 3 ) is the name 

Fig. 10. 




Angio-keratorna. (Mibelli.) 

given by Mibelli to a peculiar disease of the skin of the 
hands, feet and ears that has been called telangiectatic 
warts, or vermes telangiectasiques. 

Symptoms. It follows chilblains and affects princi- 
pally the dorsal aspects of the hands and feet, though 
^rit. Journ. Dermat., 1891, iii., 237. 



ANGIOMA SERPIGINOSUM. 103 

their plantar surface may be involved to a slight degree. 
The eruption consists in tiny, almost imperceptible, pink 
points that do not disappear on pressure ; of pin-point to 
pinhead darker spots that can be made almost to disappear 
on pressure, leaving a deep-red capillary loop in the cen- 
ter ; and of clustered telangiectatic points forming small 
irregularly shaped, slightly elevated groups. These groups 
may be as large as a split pea or bean ; they may project 
for half a line above the surface, are hard, rough, warty- 
looking and of dull purplish-brown color. Pressure upon 
them brings out the telangiectatic character of the growths. 
When pricked with a needle free hemorrhage takes place. 
The eruption is symmetrical as a rule and usually affects 
more than one member of a family. It begins in child- 
hood. There are no subjective symptoms. 

Pathology. J. A. Fordyce 1 found in his case that the 
lesions were composed of lacuna spaces filled with blood, 
occupying the papular portion of the derma. He thinks 
that the vascular changes are primary. 

Treatment. The treatment that proved most benefi- 
cial was by electrolysis. 

Angeioma (A 2 n-ji-o r ma 3 ), or Angioma. An angioma is 
a tumor or new growth made up of blood vessels or lym- 
phatics. It is usually congenital. For convenience the 
vascular angiomata will be described under Nsevus and 
the others under Lymphangioma. 

Angioma Pigmentosum et Atrophicum is the name pro- 
posed by R. W. Taylor for the xeroderma of Kaposi and is 
described in this book under Atrophoderma pigmentosum, 
which see. 

Angioma Serpiginosum. This is a rare disease, of which 
but few cases have been reported. White 2 describes the 
disease as beginning as minute papules that slowly increase 
to the size of a pea and then undergo spontaneous involu- 
tion in the central portions while they spread outward in 

'Joum. Cutan. and Gen.-Urin. Dis., 1896, xiv., 81. 
2 Journ. Cutan. and Gen.-Urin. Dis/, 1894, xii., 505. 



104 DISEASES OF THE SKIN. 

an annular form to an indefinite extent and for an indefi- 
nite period. By the end of ten years the circinate patches 
may be no larger than one or two inches in diameter. The 
margin of the rings is elevated and of uniform breadth. 
New foci continually develop at a distance of one-eighth 
to one-third of an inch beyond the older areas. These, in 
turn, are converted into rings in the same way. The 
lesions are firm and smooth and are of bright-red to claret 
color. The center of the rings is not elevated but remains 
of a dull pinkish-brown tint. There are no subjective 
symptoms. White's case was on the right shoulder. Other 
cases have been on the arm, cheeks, and leg. 

Most of the cases develop in early life. The pathology 
is undetermined. In White's case the growths were com- 
posed mostly of endothelial cells and the disease was 
thought to be of sarcomatous nature. Electrolysis is the 
only treatment suggested. 

Angioses. " Disorders of the cutaneous vascular appa- 
ratus which embrace the common effects of engorgement, 
ischsemia, transudation, and inflammation." 1 

Anhidrosis (A 2 n-hi 2 d-ro r -si 2 s), or Anidrosis (A 2 n-i 2 d-ro'- 
si 2 s). By this is meant an affection of the sweat glandular 
apparatus attended by a diminution or more or less com- 
plete suspension of its functions. It is a symptom rather 
than a disease. It may be local or general ; temporary or 
permanent ; symptomatic, as in fevers and diabetes ; con- 
genital, as in xeroderma ; or neurotic. Some people never 
sweat perceptibly. In certain skin diseases, such as pso- 
riasis, scleroderma, squamous eczema and ichthyosis, the 
affected areas do not sweat. Its treatment is tonic by 
exercise and bathing. In symptomatic cases we must 
strive to remove the underlying cause. For congenital 
cases we can do nothing. 

Anonychia (A 2 n-o 2 n-i 2 k r -i 2 -a 3 ) means congenital absence 
of the nail. 

1 Bronson : Journ. Cutan. and Gen.-Urin. Dis., 1887, v., 371. 



ATROPHIA PILORUM PROPRIA. 105 

Anthrax (A 2 n-thra 2 x). See Carbuncle and Pustula 
maligna. 

Aplasie Moniliforme. See Trichorrhexis nodosa. 

Area Celsi. See Alopecia areata. 

Argyria (A 3 r-j 2 ir-i 2/ a 3 ) is the blue or black discoloration 
of the skin and mucous membranes, due to the deposition 
of particles of silver in the rete, sweat glands and about 
the hair follicles, where it turns black by exposure to the 
sunlight. It used to be seen more often than now, when 
silver salts were administered in the treatment of epilepsy. 
It is also seen in workers in metallic silver, minute par- 
ticles of the metal becoming fixed in the tissues. It is a 
permanent staining. 

Arthritide Pseudo-exanthematique. See Pityriasis rosea. 

A steatosis (A 2 s-te-a 3 -to r -si 2 s), an absence of sebaceous 
matter. See Xeroderma. 

Atheroma (A 2 th-e 2 r-o r -ma 3 ). See Sebaceous Cyst. 

Atrichia. See Alopecia adnata. 

Atrophia Pilorum Propria. Atrophy of the hair exists 
under two forms, namely, fragilitas crinium and Trichor- 
rhexis nodosa, In both forms the hair shaft is easily 
friable and splits or breaks of itself or by the slightest 
traction. 

Fragilitas Crinium. This disease has been called scis- 
sur a pilorum, and has for its distinguishing features split- 
ting of the hair. The cleft is usually at the free ex- 
tremity, and at times runs some distance up the shaft. 
The split hairs are either scattered here and there through 
the otherwise normal hair, or all the hairs of the part are 
split. The disease occurs most often upon the scalp, the 
beard being the place next most frequently affected. It 
is a common occurrence in the long hair of women. The 
shaft may be split into two or more fibrillar, and these 
spread out from each other simply or curve up upon 
themselves. The cleft may also occur in the middle of 



106 DISEASES OF THE SKIN. 

the shaft or at its exit from the follicle, and in the latter 
case the shaft will be split throughout its entire length, 
the segments either separating or holding together. Duhr- 
ing 1 has reported a case occurring in the beard in which 
the hair began to split within the bulb. Besides the 
splitting, the hair may show no other abnormality, but it 
is generally more dry and brittle than normal, and may 
be irregular and uneven in its contour. The bulb of the 
hair may be normal or atrophied. 

Etiology. The cause of the idiopathic fragilitas crin- 
ium is yet undetermined. The disease is, without doubt, 
due to some interference with the nutrition of the hair, 
probably a yet undetermined tropho-neurosis. 

Treatment. When occurring only at the free end of 
long hairs they should be cut above the cleft. In all 
cases the scalp should be kept in good condition, as directed 
under Alopecia prematura. If the disease occur in the 
beard, shaving would at least remove the deformity and 
possibly cure the disease. 

Trichorrhexis Nodosa. Synonyms : Trichoclasia ; Tri- 
choptylose ; Clastothrix. 

Symptoms. The disease most often affects the hair of 
the beard and moustache, and here it reaches its highest 
development. It is found also in the hairs of the pubic 
region and in the scalp hair. Raymond 2 says that he has 
found it on the labia majora in 40 per cent, of all women 
he has examined and specially in fat women with inter- 
trigo. He has found it also on scrotal hairs. It consists 
of one or more whitish or grayish, shiny transparent nod- 
ular swellings occurring along the shaft of the hair. In 
people with red hair the color may be black. The num- 
ber of nodes that may be present is from one to five, and 
their size will vary with the diameter of the hair. The 
nodes, according to S. Kohn, 3 occur usually in the upper 
third of the hair. These nodes give to the hair an ap- 

^mer. Jour. Med. Sci., July, 1878, p. 88. 

2 Ann. de derm, etsyph., 1891, ii., p. 568. 

3 Vierteljahr. f. Derm. u. Syph., 1881, viii, 581. 



ATROPHIA PILOBUM PROPRIA. 



10' 



pearance not unlike that produced by the presence of the 
nits of pediculi. The hair is exceedingly brittle and 
fractures upon slight traction or spontaneously, the frac- 
ture taking place through a node and the hair fibers sep- 
arating like the hairs of a brush. When manv hairs in 
the beard are thus broken, their frayed-out ends make 




Uf 



\iM 



:%*'-' 



Trichorrhexis nodosa. (^Iichelsox. ) 

the beard look as if it were singed. Sometimes the hair 
fibers splinter about the node, but the two ends do not 
separate, and this gives an appearance like as if two small 
paint brushes were pushed together. Sometimes the hair 
presents an irregular contour and looks as if frayed along 
its entire length. While the fracture is usually trans- 



108 DISEASES OF THE SKIJSf. 

verse, if there should be an excessive amount of medulla 
present in the node it may be longitudinal. The hairs 
themselves are usually firmly fixed in the follicles. 

Etiology. The cause of the disease is probably a 
parasite. Micro-organisms have been found in relation 
to the disease by Hodara, Essen and others. Anderson 1 
has reported a case of hereditary trichorrhexis nodosa, the 
disease in his patient being congenital or nearly so. 

By some it is regarded as purely mechanical, due to the 
habit of the patient of handling the beard. 

Pathology. The microscopical examination of the 
affected hairs shows that in the early stage of development 
of the disease there is simply a spindle-formed thickening 
in the continuity of the shaft of the hair and a swelling 
of the medulla, while the cuticle is still intact. Later the 
cuticle becomes cleft, and the cleavage extends on all sides 
of the node till the brush-like appearance is produced by 
spreading of the separate fibers. At the same time with 
the cleaving of the cuticle the medulla undergoes degenera- 
tive changes. There is either no marked change in the ap- 
pearance of the hair-root or it is slightly atrophied. Air- 
globules are only very occasionally found in or about the 
nodes. 

Treatment. The treatment of the disease is very un- 
satisfactory. Continued shaving probably offers the best 
hopes. All sorts of applications have been made to the 
affected parts, generally of a stimulatiDg character, par- 
ticularly various forms of mercurials, but without curative 
effect. Gamberini, in his work on the hair, recommends 
either bathing the part with a lotion composed as follows : 



R. Potass, subcarb., 5iij I 81 

Alcohol, dil., %y; 10 °l M - 



or inunctions of tannic acid or oil of cade. 
Schwimmer advises that an ointment of 

lancet, 1883, ii. ; 140. 



ATROPHIA UNGUIUM. 109 

R . Zinci oxid. , gr. vij ; 1 5 

Sulphur, loti, gr. xv ; 3 

Ung. simp., 5iJ ss 5 30| M. 

be rubbed in the morning and evening. 

Besnier finds it useful to pluck the diseased hairs and 
to apply to the newly formed hairs tincture of cantharides, 
pure or diluted. Sabouraud advises using daily 

R. 



Hydrarg. bichlor. , 
Ac. tataric, 


gr. iv ; 
gr. viij ; 




20 

40 


Eesorcin., 
Alcohol. , 
Ether., 


gr. xv-xxx ; 

aa gjss; 


1-2 

50 





M. 

A two per cent, solution or ointment of pyrogallol or 
a three per cent, carbolic acid ointment has been advised 
by others. 

Allied to trichorrhexis nodosa we have Monilethrix, 
or ringed hairs, in which the hair shaft is marked by 
alternate swellings and constrictions, the latter being color- 
less. The hairs are liable to fracture through the con- 
stricted portion in this way differing from trichorrhexis 
nodosa. 

Atrophia Unguium. Atrophy of the nails occurs as a 
symptom of very many diseases of the skin, such as 
lichen ruber acuminata, pityriasis rubra, psoriasis, and 
syphilis ; or it may be caused by the invasion of the nail- 
bed by parasites, as in favus and ringworm. It may also 
occur like defluvinm capillorum as a sequence to some 
grave acute illness, such as typhus fever or scarlatina, or 
some cachexia, such as diabetes. The nails may be con- 
genitally absent or deficient, or become so without ap- 
parent cause. Injuries and certain chemicals will cause 
the nails to atrophy and fall. Atrophy is shown by white 
spots in the nails, by loss of lustre, by transverse white 
lines, by longitudinal or transverse furrows, by a worm- 
eaten appearance, or by a general thinning and breaking 
away of the nail-plate. 

Treatment. The treatment is most unsatisfactory. 



110 



DISEASES OF THE SKIN. 



If the cause can be discovered and removed, the nails will 
recover. In many cases all we can do is to protect the 
nail by rubber cots or by the use of wax or other pro- 
tective. Ointments of lead, zinc, or mercury may be 
rubbed in. The persistent use ol sulphur ointment, com- 
bined with the' administration of nerve tonics, will prove 
beneficial in those cases apparently dependent upon nerve 
disturbance. 



Atrophoderma, or Atrophia Cutis. Atrophy of the skin 
may be quantitative or qualitative ; idiopathic or sympto- 
matic ; diffused or circumscribed. Crocker x gives this 
useful table : 



Atrophoderma 
Idiopathicum. 



Atrophoderma 
Symptomaticum. 



f Juvenilis 
Diffusum -{ 

L Senilis 

Circumscriptum 
(striae et maculae) 

' Neuriticum 

(glossy skin) 



Morborum cutis. 



Pigmentosum. 

Albidum. 

Quantitativum. 

Qualitativum. 

Traumaticum. 

Non-traumaticum. 

Traumaticum. 

Non-traumaticum. 

Scleroderma. 

Seborrhoea. 

Lupus. 

Syphilis. 

Favus, etc. 



The symptomatic atrophies due to other diseases will be 
spoken of under their proper headings. The other forms 
of atrophy will be considered here. 

Atrophoderma Pigmentosum. Synonyms : Xeroderma 
pigmentosum (Kaposi) • Angioma pigmentosum et atro- 
phicum (Taylor) ; Dermatosis Kaposi (Vidal) ; Liodermia 
essentialis cum melanosi et telangiectasia (Neisser) ; Mel- 
anosis lenticularis progressiva (Pick) ; Lentigo maligna 
(Piffard) ; Epitheliomatose pigmentaire (Besnier). This 
is a very rare disease of the skin, first described by Kaposi 
in 1870 under the name of xeroderma, to which he subse- 
quently added the adjective pigmentosum. Only some 



1 Diseases of the Skin. Lond. and Phila., 1888. 



ATROPHODERMA. 



Ill 



fifty-six cases have been reported. It is a congenital dis- 
ease ; almost all cases begin before the second year of life. 
Symptoms. It affects the parts most exposed to the 
air ; the face, neck, chest and back down to the level of 
the clavicles, or even the third rib, the backs of the 
hands, forearms and upper arms. The hands, face and 
neck are most markedly diseased, while a few cases have 
occurred upon the legs and backs of the feet. It begins 



Fig. 12. 




Atrophoderma pigmentosum. (After Crocker.) 



with erythematous patches, like those produced by sun- 
burn. After a time brown or black freckle-like spots 
form upon the erythematous ones. They are from pin- 
head to bean size and round or irregularly shaped. Small 
red spots appear among the pigmented lesions, which 
Taylor thinks are their forerunners. The pigmented 
spots in time give place to white atrophic ones, and the 



112 DISEASES OF THE SKIN. 

skin becomes too small for the underlying parts, so that 
it appears drawn and in some places bound down. A 
fully developed case presents a vast number of lentig- 
inous spots, interspersed with white atrophic spots and 
stellate and striated telangiectases. After a time, on ac- 
count of the atrophy of the skin, we find ectropium, 
thinned alse nasi, and contracted nasal and oral orifices. 
There may be white atrophic spots on the mucous mem- 
brane of the lips. Conjunctivitis generally supervenes 
upon the ectropium and discharge from the eyes sets up 
ulcerations which in their turn give rise to other ulcer- 
ations. Warty growths at last appear, and these are prone 
to take on malignant action and be converted into epithe- 
liomas, and the patient dies at an early age from maras- 
mus. At first, however, there is no disturbance of the 
health. 

Etiology. The etiology of the disease is obscure. It 
is supposed by some to have its starting point in irrita- 
tion of the skin by the sun or other irritant. Many of 
the cases begin in the summer. It is supposed by others 
to be a tropho-neurosis. It is found in both sexes, but is 
peculiar in affecting several members of the same family 
and of the same sex, and in occurring in the first or sec- 
ond year of life. It is not hereditary. In a few of the 
cases there was a history of cancer. 

Diagnosis. The disease is to be differentiated from 
scleroderma by the peculiarity of its being limited to ex- 
posed parts, by lacking stony hardness, by occurring early 
in life and by the general picture of pigmented and atro- 
phic spots and telangiectases being intermingled. It dif- 
fers from urticaria pigmentosa in not itching, in not occur- 
ring upon the trunk and in having telangiectases and 
warty or epitheliomatous growths. 

Treatment. Nothing has yet been found to stop the 
progress of the disease. The conjunctivitis is to be cared 
for, the ulcerations on the face healed as rapidly as possible, 
and the warty growths and epitheliomatous nodules de- 
stroyed at an early date so as to prevent the development 



ATROPHODERMA. 113 

of epitheliomatous or carcinomatous ulcers. A saturated 
solution of boric acid will do much for the eyes ; the ulcers 
may be treated with iodoform or aristol powder or a dilute 
ammoniate of mercury ointment, while the warty growths 
should be scraped off with a curette. 

Atrophoderma Albidum is the name used by Crocker for 
a second form of the xeroderma pigmentosum of Kaposi, 
which is described, by the latter as beginning in childhood, 
affecting most frequently the lower extremities and less 
often the forearms and hands, and characterized by thin- 
ness of the skin, which in some places is stretched and 
cannot be readily taken up into folds. The color of the 
skin is pale and white, with a delicate rosy shimmer in 
places, and here and there its epidermis peels off in asbes- 
tos-like lamellae. The treatment is simply protective. 

Atrophoderma Idiopathica Diffusa. Diffused idiopathic 
atrophy of the skin is a very rare affection. It may be 
congenital or acquired, general or partial. The subcu- 
taneous tissue disappears, so that the skin lies close to the 
underlying parts. It is thin, pale, stretched, easily mov- 
able over underlying parts, and allows the blood vessels 
to show through. In some cases thick scaly plates form, 
while in others these are wanting and there is only slight 
scaling. The elasticity of the skin is lost, so that if it is 
pinched up into folds these slowly flatten out. In some 
cases the skin seems too small for the body, which, on the 
face, gives rise to ectropion and other deformities. The 
sensibility of the skin may not be diminished. The pa- 
tients are susceptible to cold. Ulcers are prone to form 
upon slight injuries. The hair is destroyed. The disease 
is probably a tropho-neurosis. One case was ascribed to 
exposure to cold. 1 

Hardaway 2 reported two cases occurring in a brother 
and sister ; and Ohmann-Dumesnil 3 has met with a case 

1 Pospelow: Ann. de derm, etsyph., 1886, vii., 505. 

2 Trans. Amer. Derm. Association, 1884. 

3 Alienist and Neurologist, July, 1890. 



114 DISEASES OF THE SKIN. 

of atrophy of the skin and muscles of the right arm appar- 
ently following an injury to the radial nerve by means of 
a burn on the hand. 

One variety of diffused idiopathic atrophy of the skin is 
that called hemiatrophia facialis progressiva, in which only 
one-half of the face is affected, and the skin becomes 
thinned and shrunken so that it lies close to the bones. 

Under this heading may also be placed the glossy skin 
of Paget, Weir Mitchell and others. It commonly affects 
the fingers, less often the extremities and follows upon dis- 
ease or injury of nerves. The fingers become dry, red or 
mottled, look glazed or as if varnished, and are shrunken. 
The natural lines of the skin disappear and the nails fall 
off. If parts covered with hair are affected, the hair falls. 
The tendency is to spontaneous recovery. 

Atrophoderma Senilis is a true atrophy of the skin that 
takes place in consequence of advancing years. Other 
degenerative changes are also present, as a rule. It may 
be partial or general. The skin looks wrinkled ; it is 
thrown into folds, is dry and sometimes scaly, and is 
often of darker color than normal. By pinching up the 
skin the thinness of it is readily appreciated. With the 
atrophy of the skin there are likewise loss of the subcuta- 
neous fat, pruritus and verruca senilis. Treatment is out 
of the question. 

Atrophoderma Striatum et Maculatum. By this is 
meant circumscribed atrophic streaks or spots. They may 
be idiopathic or symptomatic. The idiopathic form is far 
more rare than the symptomatic form. 

Symptoms. The idiopathic streaks are met with most 
often about the thighs, buttocks and lower anterior part of 
the abdomen. They are one or two lines wide, slightly 
curved and from one to several inches long. There are 
usually several present, and then they are arranged par- 
allel to one another and run in an oblique direction. The 
macules are isolated, from pinhead to finger-nail size or 
larger, occur most frequently on the lower part of the 



BAELZEW S DISEASE. 115 

trunk, but may occur as high up as the neck, and are less 
common than the streaks. Both forms of lesion are de- 
pressed below the surface of the skin and of a pearly or 
bluish-white color and have a glistening, scar-like appear- 
ance. They are not primary atrophies, but succeed to an 
erythematous hypertrophic lesion, in this greatly resem- 
bling morphcea. They give rise to no inconvenience, and 
are accidentally discovered. They usually are permanent, 
though they may become less pronounced in time. 

Etiology. Their etiology is obscure. By many they 
are regarded as tropho-neuroses. Shephard 1 and Duck- 
worth 2 have reported cases of atrophic spots and lines fol- 
lowing fevers. 

Symptomatic lines and macules are very common and are 
caused by the stretching or rupture of the more super- 
ficial bundles of white and elastic fibrous tissues of the 
skin. If the fibers are ruptured, the striae will be most 
pronounced and there will be little left of the skin but 
the epidermis and a thin fibrous membrane. 3 This form 
of atrophy of the skin is seen upon the abdomen of preg- 
nant women (linece albieantes) and on the breasts of nurs- 
ing women. In fact, anything that greatly distends the 
skin may give rise to them, such as abdominal ascites, 
ovarian or other tumors. 

Tkeatmext. The treatment of these cases is purely 
expectant. Both the idiopathic and symptomatic atrophies 
may grow less pronounced in time. 

Aussatz. See Leprosy. 

Autographism. See Urticaria factitia. 

Arzneiexantheme. See Dermatitis medicamentosa. 

Baelzer's Disease of the lip is a chronic affection of the 
mucous glands of the lip marked by an indolent swelling 
and infiltration of the periglandular tissue, and a sIoav 
ulceration from above downward. It ceases only with the 

1 Trans. Amer. Dermat., Assn., 1890, p. 23. 

2 Brit. Journ. Dermat., 1893, v., p. 357. 

3 Taylor, E. W. 3 N. Y. Med. Journ., 1886, xliii., p. 1. 



116 DISEASES OF THE SKIN. 

destruction of the affected gland. The neighboring lym- 
phatic glands are not implicated. A superficial catarrhal 
inflammation of the mucous membrane of the lips fre- 
quently accompanies the process. There is no general 
systemic disturbance. It has no relation either to syphilis, 
tuberculosis or cancer. It is regarded as a local infection. 
It is readily cured by the application of tincture of iodine, 
which at first is used every other day, and later every day. 

Baker's Itch. See Eczema. 

Baldness. See Alopecia. 

Barbadoes Leg. See Elephantiasis. 

Barber's Itch. See Trichophytosis barbae. 

Birth-mark. See Naevus. 

Biskra Bouton, or Biskrabeule. See Aleppo boil. 

Blackheads. See Comedo. 

Blasenausschlag. See Pemphigus. 

Blutfleckenkrankheit. See Purpura. 

Blutgeschwiir, or Blutschwar. See Furunculus. 

Blutschweiss. See Hsematidrosis. 

Boil. See Furunculus. 

Bouton d'Amboine. See Yaws. 

Brandrose is a phlegmonous erysipelas. 

Brandschwar. See Carbuncle. 

Bricklayer's Itch. See Eczema. 

Bromidrosis (Broni-Pd-ro'sPs). Synonym : Osmidrosis. 
This word means stinking sweat, which, though not ele- 
gant, is expressive. It most often affects the feet, and 
then is associated with hyperidrosis. It may be general, 
as in the negro race. The odor is not necessarily repul- 
sive, a few cases having been reported in which it was 
that of violets. The axilla? are, next to the feet, the most 



BROMIDROSIS. 117 

common site of the trouble. The odors of different fevers 
and cachexias are usually classed under this heading, though 
they do not properly belong here. 

Strictly speaking, bromidrosis should include those rare 
cases alone in which the sweat, when secreted, has a dis- 
tinctive odor. Usually the odor in bromidrosis is not in 
the sweat, but in the products of decomposition, the fatty 
acids and the like. When the feet are the parts affected 
they will be found to be of a pinkish color about the soles 
and between the toes, or the skin will look sodden and 
grayish. When the hyperidrosis is well marked, and it 
commonly is, the feet may be so tender as to interfere with 
locomotion. The stench from a pronounced case is such 
that it is almost impossible to stay near the subject of the 
disease. 

Etiology. The cause of general bromidrosis is either 
inherent in the race or unknown. Most of the cases, apart 
from the racial ones, have been in hysterical subjects. In 
the usual form of the disease it is due to decomposition of 
the sweat in the stockings, shoes or clothing of the indi- 
vidual. When the part is uncovered and kept clean there 
is no odor. Thin has described a parasite, that he has 
named bacterium foetidum, as the cause of the disease. It 
has been supposed that this bacterium can live only in an 
alkaline medium. The sweat is acid, and, therefore, on 
most feet it does no harm, but when hyperidrosis macer- 
ates the epidermis and allows of the escape of serum the 
acidity of the sweat is neutralized and the bacterium flour- 
ishes. 

Treatment. The treatment of the general cases is of 
no effect. In the local cases the hyperidrosis is to be over- 
come, as will be described in its proper place. The special 
treatment directed to the cure of the odor of the feet is to 
wash them with soap and water two or three times a day, 
to put on a clean pair of stockings every morning, to ven- 
tilate the shoes thoroughly and to dust the feet, between 
the toes, the stockings and the inside of the shoes with 
boric acid. Thin recommends the wearing of cork inside 



118 DISEASES OF THE SKIN. 

soles, which are to be soaked in a saturated solution of boric 
acid and dried before using. Another useful powder is : 



R . Ac. salicylici, 5J ss_ iiJ '■> 5-10 

Pulv. alum exsi< 
Puiv. lycopodii, 



Pulv. alum exsic. vel. \ %••• . -inn 



M. 



to be applied in the same way, twice a day. This will 
cause the skin to exfoliate, when the treatment may be 
stopped. 

W. Osier 1 reports one case of general bromidrosis cured 
by alkalies. 

Bucnemia Tropica. See Elephantiasis. 

Bulpiss 2 is a disease that occurs in Nicaragua, affect- 
ing every tribe, both sexes and all ages, though rare 
in early infancy. It begins on the feet and hands, 
and spreads gradually, or upon the knees, or abdomen, 
or neck and face. Two kinds are described. In the white 
bulpiss we have crops of minute reddish papules, which 
on disappearing leave discolored spots. After a time the 
pigmentation fades away and leaves a dirty white, round 
or oval patch, with slightly elevated and partly discol- 
ored broad margins. In black bulpiss the patches are 
grayish-black, and the skin is dry and shriveled. Both 
kinds itch at night. It is contagious and probably para- 
sitic. 

Bunion. According to P. Syms 3 a bunion is always sec- 
ondary to an outward displacement of the first phalanx 
of the great toe due to ill-fitting shoes. As a result we 
have a periostitis with hyperplasia, and finally exostosis 
of the metatarsal bones. The pressure between the exos- 
tosis and the shoe gives rise to an inflamed bursa, the 
bunion. Surgical interference and properly constructed 
shoes are the only remedies. 

Cacotrophia Folliculorum. See Keratosis pilaris. 

1 Montreal Med. Jour., 1896-7, xxv., 890. 

2 0. Lerch, New Orl. Med. and Surg. Jour., 1894-5, xxii., 793. 

3 N. Y. Med. Jour., 1897, lxvi., 448. 



CANITIES. 119 

Calculi, Cutaneous. See Milium. 

Callositas (Ka 2 l-loVi 2 t-a 2 s). Synonyms : Callosity ; Cal- 
lus ; Tylosis ; Tylonia ; (Fr.) Durillon. This is familiar 
to all as the callous skin of the hands met with in oars- 
men, blacksmiths, and in those who follow other manual 
occupations, and is a hypertrophy of the epidermis con- 
sequent upon intermittent pressure of the skin against the 
underlying bone. Constant pressure will cause atrophy. 
The same thickening of the skin is found upon the soles 
also, due to going barefoot or wearing improperly-fitting 
shoes. In fact, it may develop anywhere under proper 
conditions. 

Treatment. ~No treatment is necessary for the ac- 
quired forms. Cessation from using the hands will be 
followed in course of time by the disappearance of the 
callus. To hasten its removal we may use maceration 
with rubber cloth continuously applied to the part, or a 
plaster of salicylic acid, or a solution of salicylic acid ten 
to twenty per cent, in ether or collodion. The action of 
these remedies will be aided by previously paring down 
the part with a sharp knife. 

Callus. See Callositas. 

Calvez "| 

Calvezza V See Alopecia. 

Calvities J (Ka 2 l-vi 2 -s'h'i 2 ez). 

Cancer. See Carcinoma and Epithelioma. 
Cancroide. See Epithelioma. 

Canities (Ka 2 n-i 2/ shi 2 -ez). Synonyms : Trichonosis 
cana ; Trichonosis discolor ; Poliothrix ; Poliosis ; Trich- 
onosis poliosis ; Spilosis poliosis ; Poliotes ; Grayness of 
the hair ; Whiteness of the hair ; Blanching of the hair ; 
Atrophy of the hair pigment. 

Grayness or whiteness of the hair may be congenital 
or acquired ; the latter is by far the most common. The 
whiteness is either partial or complete. 



120 DISEASES OF THE SKIN. 

Congenital canities usually occurs in the form of tufts, 
sometimes in round patches, the more or less pure white 
hair showing conspicuously amongst the normal-colored 
mass. When the whiteness is general we have albinism, 
which is associated with a deficiency of pigment in the 
whole body. Cases of congenital canities are rare. 

Acquired canities may be premature or senile. Most 
often grayness does not begin before the thirty-fifth or 
fortieth year. If it occurs before this age it may be con- 
sidered as premature ; and when after this age as senile. 
Premature canities is by no means uncommon, many per- 
sons becoming gray between the twentieth and twenty- 
fifth year. The hair which, as a rule, first whitens is 
that of the temples ; then follows, with more or less 
rapidity, that of the vertex and whole head. Sometimes 
the beard first turns gray, but usually it changes color after 
the hair of the scalp. The last hair to become gray is 
that of the axillae and pubis. When the graying is due 
to some passing cause, as anxiety or some diseased state, 
the process may cease completely upon removal of the 
cause. Usually the whiteness is permanent. As a rule, 
there is no change in the color of the scalp, though in 
some cases gray tufts are found upon pale yellow patches 
of scalp. As in alopecia, so in canities, men are more 
frequently affected than women. 

The hair in canities is usually unchanged except in 
color, but it may be drier and stiffer than normal. Cani- 
ties may exist for years without alopecia. 

The hair turns gray first at its root. The color at first 
is gray on account of the mixture of the normal color with 
the whiteness due to the absence of pigment. Gradually, 
the white parts gain the ascendant, and the whole hair is 
blanched, becoming finally of a yellowish or snowy white- 
ness. The darker the hair is originally the more it is 
prone to turn gray. 

Sudden change of color of the hair from its normal hue 
to perfect white has been too well authenticated to allow 
of a doubt as to its occurrence, though it has been denied 



CANITIES. 121 

by good authorities , who have questioned the correctness 
of the observations reported. 

Ringed hair is an anomalous variety of blanching of the 
hair in which the affected hairs are marked by alternate 
rings/ one being that of the normal color, and the next 
white. The occurrence of this disease is very rare and 
but few cases have been reported. 

The hair has been known to lose its color under varying 
circumstances. Very commonly the first hair that comes 
in after alopecia areata is white. Wallenberg 1 reports a 
case in which, after an attack of scarlatina, the patient's 
brown hair was entirely lost and replaced by a growth of 
white hair. Prolonged residence in a cold climate, with 
much exposure, will cause the hair to turn gray. Some- 
times the hair will change its color with the season, becom- 
ing gray in winter and darker in summer. On the other 
hand, Cottle 2 gives prolonged residence in hot climates, 
with much exposure, as a cause of canities. Albinoes, 
we know, are most frequent in the negro races, which 
inhabit the hot countries. 

Etiology and Pathology. Senile canities and many 
cases of the premature form are due to an obscure change 
in the nutrition of the hair papillae which interferes with 
the production of pigment. Only this function of the 
papillae seems to be interfered with, as the hair-forming 
function is in full activity, judging from the fact that the 
hair in many cases is in full vigor. In cases of sudden 
blanching of the hair the change of color is dependent 
upon the formation of air bubbles between the hair cells 
of the cortical substance, the presence of the air rendering 
the cortical substance opaque, so that the color of the pig- 
ment is obscured. There are various agents which act as 
active or exciting causes of canities. Age is one of the 
most prominent of these. Heredity exerts marked influ- 
ence upon the blanching of the hair, most of the members 
of certain families turning gray at an early period of life. 

1 Yrtljhrschrft f. Derm, und Svph., 1876, iii., 63. 

2 The Hair in Health and Disease. London, 1877. 



122 DISEASES OF THE SKIN. 

Neuralgia of the fifth nerve, dyspepsia of various forms, 
sudden fear or nervous shock (producing sudden blanching 
of the hair) , profuse and frequent hemorrhage, excesses 
of all kinds, chronic debilitating diseases (as syphilis, ma- 
laria and phthisis), local diseases or injuries to the scalp, 
as wounds, favus, repeated epilation, prolonged shaving 
and the like have been given by various writers as causes 
of canities. Schwimmer regards it as being principally a 
tropho-neurosis and finds in the occurrence of grayness in 
the course of neuralgia a strong argument for his theory. 

Treatment. We cannot restore the color to gray 
hairs. In some cases of canities occurring in the course 
of neuralgias, if we can cure the neuralgia, the color will 
gradually return to the hair. 

Besnier and Doyon suggest the use of acetic acid as a 
promoter of pigmentation, as they have seen numerous 
cases of its use in Alopecia areata being followed by the 
growth of hyper-pigmented hair. 

All that can be done for canities is to restore artificially 
the color by means of hair dyes, and their use is to be 
deprecated. Happily the custom of dyeing the hair is 
falling out of fashion. 

Carates. See Pinta. 

Carbuncle (Ka 3 rb r -u 3 n-kl). Synonyms : Anthrax, 1 Car- 
bunculus ; (Ger.) Brandschwar. 

A phlegmonous inflammation of the skin and subcu- 
taneous tissue, attended with sloughing. 

Symptoms. The disease begins as an innocent-looking 
papule, which, however, is far more painful, both subjec- 
tively and objectively, than an ordinary papule would be. 
Within twenty-four hours it becomes larger, more pain- 
ful, slightly raised and reddened, and is generally accom- 
panied by a good deal of constitutional disturbance, such 
as chills, fever and nervous irritation. All the symptoms 
increase in severity, the inflammation extends laterally 

1 Anthrax, a term that is often applied to carbuncle, should be used 
rather for malignant pustule or the local manifestation of splenic fever. 



CARBUNCLE. 123 

and vertically, the swelling becomes darker in color, the 
pain more intense, throbbing and lancinating, and the con- 
stitutional disturbance may be so severe that the patient 
is compelled to go to bed. Within ten days, or perhaps 
longer, the swelling has reached its height. It may be 
two or three inches wide, with a brawny base that is more 
or less sharply denned, of irregular shape, firm to the touch 
and with a wide area of eedematous skin about it. ISTow 
it begins to soften, not like a boil with a central point, 
but by the formation of a number of pea-sized purulent 
points, through which sanious pus exudes, giving to the 
surface a cribriform appearance. Sloughing takes place 
through the openings, that gradually enlarge, so that at 
last there results an irregular, deep, excavated ulcer with 
firm, sharply cut, everted edges. In very bad cases the 
whole mass may fall out at once. The ulcer gradually 
fills up, heals and leaves a scar. With the discharge of 
the slough the patient gradually recovers his health, but 
in some cases, especially in already debilitated or in 
elderly people, the disease runs a fatal course, and they 
die of exhaustion or pyaemia, or the disease runs into a 
typhoid condition preceding death. Death may also 
result from acute sepsis, or from thrombosis or embolus, 
especially in carbuncles on the scalp. In some cases the 
resulting ulceration is very large, with a corresponding 
amount of general disturbance of the system. Dry gan- 
grene may take place. 

The disease is rare in children, and most common in 
middle and old age. Men suffer more often than women. 
The location of the disease is most often the upper dorsal 
region, back, buttocks and forearms, though it may occur 
anywhere. It is usually a single lesion. The duration 
of the whole process is six weeks or more. 

Etiology. The causes of the disease are very much 
the same as those of boils. While carbuncle is most apt 
to occur in those who are not in good health, it does occur 
at times in apparently robust subjects. Diabetics are fre- 
quent subjects ; gout and uraemia have been considered as 



124 DISEASES OF THE SKIN. 

predisposing causes. The frequent location of the disease 
about the shoulders and on the back of the neck suggests 
pressure as a determining cause. Micro-organisms are the 
exciting cause of the disease, the staphylococcus pyogenes 
aureus being constantly found in the tissues of a carbuncle. 

Pathology. To Warren/ of Boston, we owe one of 
the most thorough studies of the pathology of carbuncle. 
He declares it to be a spreading phlegmonous inflamma- 
tion of the subcutaneous cellular tissue. The inflamma- 
tory cells cluster in and about the columnar adiposse and 
push out laterally from them, infiltrating the skin. They 
reach the surface by mounting up along the hair follicles 
and arrectores pilorum muscles. 

Diagnosis. Carbuncle differs from furuncle in being 
single ; in its brawny base ; in its greater painfulness and 
constitutional disturbance ; in its flatter shape and larger 
size, and especially in its opening at many points and pre- 
senting a cribriform surface rather than a central core and 
a crater-shaped opening. Its circumscribed shape, its lan- 
cinating pain and its multiple sieve-like openings distin- 
guish it from diffuse plilegynonous inflammation of the skin. 
Anthrax becomes gangrenous earlier than carbuncle and its 
center sinks in instead of being elevated. 

Treatment. As the disease is an exhausting one the 
patient's strength is to be supported from the start and his 
nutrition kept up by a generous diet. Fresh air by good 
ventilation must be secured. If the pain is excessive 
opium or morphine is indicated, especially to procure 
sleep. Iron is a valuable remedy all the way through, 
and antipyretics should be administered if the fever is 
marked. Alcohol should be given if suppuration is free, 
especially if there are any signs of exhaustion. 

The best local treatment in mild cases is the use of car- 
bolic acid, and this gives such good results as to leave little 
to be desired. The crucial incision formerly practised is 
now considered by most modern authorities as harmful, 
though it certainly gives relief for the time by removing 
Boston Med. and Surg. Journ., 1881, civ., 5. 



CARCINOMA. 125 

tension. In like manner the old-time method of poultic- 
ing is condemned, though it, too, contributes to the comfort 
of the sufferer. For ordinary carbuncles the most efficient 
treatment is to inject them at several points with a five or 
ten per cent, solution of carbolic acid in olive oil or glycer- 
ine, by means of an ordinary hypodermatic syringe. When 
there are already sloughing points it is well to push into 
each of them a little cotton wound on the end of a wooden 
toothpick and dipped in carbolic acid either pure or in 
one to four solution. These procedures are painful for a 
moment. The mass must then be covered with lint 
soaked in a weak solution of carbolic acid. It is possible 
to abort some cases by touching them with pure carbolic 
acid. Eade * says that it is possible to abort cases in the 
papular stage by continuous soaking with a solution of a 
mild antiseptic, such as boric or salicylic acid. 

Canquoin's paste and a solution of chloride of zinc, 1 
to 50, have been recommended for use in the same way 
as the carbolic acid. 

Extensive carbuncles are to be treated on surgical prin- 
ciples by incision or erosion with the curette. The result- 
ing raw surface, as well as that of ordinary carbuncles, is 
to be dressed antiseptically with iodoform, iodol or aristol 
in powder. 

Carcinoma (KaVsrn-o'ma 3 ). Epithelioma is the form 
of cancer that most frequently is met with in the skin. It 
will be described under its proper heading. Carcinoma 
of the scirrhous variety rarely attacks the skin, but when 
it does it may be primary or secondary. Most commonly 
it is secondary to the same disease of the breast or inter- 
nal organs. It may follow extirpation of the primary 
deposit, and then is prone to begin in the scar. Two 
varieties are described, namely : Carcinoma lenticulare 
and Carcinoma tuberosum. 

Carcinoma Lenticulare generally appears on the chest 
in the neighborhood of the breast and secondary to a 
mammary cancer or in the scar resulting from a previous 
1 Lancet, May 19, 1888. 



126 DISEASES OF THE SKIN. 

operation for the removal of a cancer of the breast. It 
appears in the form of smooth, firm, glistening, dull or 
brownish-red or pinkish nodules raised above the surface 
and discrete at first. In size the nodules vary from that 
of a pea to that of a bean. After a time the nodules run 
together and form a thick, indurated mass, which may in- 
volve so much of the chest as to interfere with breathing. 
This is the cancer en cuirasse of Velpeau. Now the 
neighboring lymphatic glands are involved and the arm of 
the same side becomes swollen and useless. In a short 
time the nodules and the mass break down and ulcerate, 
and the patient soon dies of exhaustion. 

Carcinoma Tuberosum is still more rare. It may occur 
anywhere, but is most frequently seen upon the face and 
hands. It takes the form of disseminated, flat or elevated, 
round or oval tubercles or nodules, seated deeply in the 
skin and subcutaneous tissues. These are of a dull-red, 
violaceous or brownish-red color. They do not tend to 
run together, but they break down and ulcerate, and the 
patient dies just as in the lenticular variety. It usually 
appears in old people. 

In both forms there may or may not be lancinating 
pains, or there may be simply itching. In both, metasta- 
sis may take place. 

Carcinoma Melanodes is described by most authors as 
a third form of carcinoma, but Robinson, Crocker, and 
Brocq regard it as melanotic sarcoma. It is impossible to 
distinguish them clinically from sarcoma, which see. 

Diagnosis. The diagnosis of carcinoma is not difficult 
when one is aware that there is such a disease and knows 
that in a given case there has been, or is, a carcinoma else- 
where. The mode of evolution of the lesions, the involve- 
ment of the lymphatic glands and the lancinating pains 
all point toward carcinoma as against a tubercular syphi- 
lide, lupus or leprosy. 

Treatment. The treatment of carcinoma of the skin 
is the same as of other forms and quite as unsatisfac- 
tory. 



CHLOASMA. 127 

Causalgia (Ka 4 s-a 2 Fji 2 -a 3 ). Neuralgia with a sense of 
severe burning pain. 

Chair du poule. See Cutis anserina. 

Chancre. See Syphilis, initial lesion of. 

Chap. Usually a mild form of eczema or dermatitis, 
attended with superficial cracking. It is generally due to 
exposure to cold and affects exposed parts, as the backs 
of the hands and the lips. Thorough drying of the hands 
after washing and keeping them covered from the air will 
prevent its occurrence on the hands. Avoiding wetting 
the lips, and making some greasy protecting application, 
such as camphor ice, will prevent the lips from being 
affected. 

Charbon. See Carbuncle. 

Cheilitis (Kil-i'-tis) glandularis is a disease of the lips, 
usually the lower one. The lip becomes gradually swol- 
len, firm and rather hard to the touch, and its mobility 
is impaired. The mucous glands become swollen and can 
be felt as nodular masses. A turbid muco-purulent secre- 
tion is poured out at times, and the gland ducts are more 
or less dilated. No pain attends the disease, which is 
exceedingly obstinate to treatment. Black wash is recom- 
mended in treatment, together with the occasional appli- 
cation of nitrate of silver. 

Cheiro-pompholyx. See Pompholyx. 

Chelis and Cheloide. See Keloid. 

Chilblain. See Dermatitis congelationis. 

Chloasma (Klo-aVma 3 ). Synonyms : (Fr.) Chloasme, 
Panne hepatique, Tache hepatique, Chaleur du foie, 
Masque ; (Ger.) Pigmentflecken, Leberflecken ; (Ital.) 
Macchie epatiche ; (Eng.) Liver spot, Moth patch, Mask. 

A pigmentary disease of the skin, characterized by the 
formation of yellowish, brownish or blackish patches of 
various sizes and shapes. 



128 DISEASES OF THE SKIN. 

Symptoms. In this disease the only alteration of the 
skin is its color. The disease consists in a deposit of 
pigment in the rete mucosum and occurs in the form of 
circumscribed or diffused patches of yellowish to black 
discoloration. When the color is black it is called melasma, 
or melanoderma. The size of the patches varies greatly 
from a small spot up to a general bronzing of the skin. 

The disease may be primary or secondary, idiopathic or 
symptomatic. The idiopathic forms are most often second- 
ary to some irritation. Thus it occurs with or in conse- 
quence of irritants applied to the skin, whether blisters or 
even sinapisms ; prolonged scratching on account of some 
pruriginous disease, such as prurigo, pruritus cutaneous, 
chronic urticaria, scabies or pediculosis ; exposure to the 
sun's rays or high winds, or even to heat, as of the furnace 
in iron workers, and then on exposed parts. These all 
cause more or less hyperemia of the skin, and besides the 
deposit of the pigment there is more or less discoloration 
from the changes taking place in the extravasated blood. 
Allied to these causes and acting in the same way is the 
discoloration of the skin of the legs met with about old 
varicose ulcers and sometimes without the ulcers when 
there are marked varicosities. 

The symptomatic form may likewise be primary or 
secondary. It is primary in that most common form of 
all that is known as Chloasma uterinum, or the mask, a 
form of hyper-pigmentation of the skin of the face that 
occurs during pregnancy, or with uterine irritation, and 
that is not met with after the menopause. It usually 
takes the shape of a diffused brownish, light or dark, dis- 
coloration of the forehead alone, or also about the mouth 
and cheeks. Usually it extends only across the forehead 
and down the temples and is either a continuous or inter- 
rupted patch with sharply defined borders. Under the 
same conditions there takes place a deepening of the color 
about the nipples and along the linea alba. The darken- 
ing of the color under the eyes of menstruating women is 
largely due to vascular congestion and little, if it at all, to 



CHLOASMA. 129 

chloasma. After a time in some women true chloasma 
does occur there. 

Primary pigmentation also occurs in certain cachexia?, 
such as Addison's disease, tubercular leprosy in Euro- 
peans, abdominal tuberculosis, cirrhosis of the liver, 
cancer of the stomach, malaria and multiple melanotic 
sarcoma. There is also an earthy look to the skin in sec- 
ondary syphilis, as well as in congenital syphilis. Pri- 
mary chloasma is also seen as the result of the ingestion of 
arsenic. Argyria is not a chloasma, strictly speaking. 

Secondary symptomatic chloasma is seen as the sequela 
of syphiloderma and of lichen ruber planus ; these derma- 
toses disappearing to leave behind them, for a greater or 
less length of time, hyper-pigmented spots. This may 
occur after other diseases of the skin, but is usually more 
fugitive. It is also seen in senile atrophy of the skin. 
There is hyper-pigmentation about the patches of leuco- 
derma and in scleroderma. There is also a pigmentary 
syphilide met with upon the neck in women. 

Etiology. The cause of chloasma is undetermined in 
most cases. A late theory of the pigmentation following 
exposure to the sun is that it is due to the action of the 
chemical rays of the sun upon the constituents of the 
blood. We know also that in some cases of hyper-pig- 
mentation the color is due to changes taking place in the 
coloring matter of the extravasated blood. That there is 
a relation between chloasma uterinum and the uterus we 
know, because the chloasma usually clears away either 
after parturition, the cure of the uterine disorder, or the 
attainment of the menopause. 

Diagnosis. The diagnosis is usually easy. Discolora- 
tions caused by artificial means can be washed off. Chromo- 
2)hytosis is scaly and can be scraped off with the nail. 
Chromidrosis is very rare and can be washed off with 
chloroform or ether. 

Treatment. The treatment of chloasma is very un- 
satisfactory. In many of the symptomatic cases removal 
of the cause will be followed by disappearance of the color. 
9 



130 DISEASES OF THE SKIN. 

Our first duty is to try and find the cause and, if possible, 
remove it. While it is possible to remove the color, it is 
very prone to return. Acetic acid touched on in spots 
will reduce the color and sometimes remove it. The same 
may be said of other acids, care being used not to cause too 
great destruction of the skin by the stronger ones. The 
bichloride of mercury in 1 to 2 per cent, solution may be 
used for the purpose, applied repeatedly or else kept on 
continuously for three or four hours. It is not always a 
safe procedure. Salicylic acid, 10 to 15 per cent., in 
ointment, paste or plaster, or in saturated solution in 
alcohol, may do well. Unna has recommended washing 
the part with alcohol and applying a mercurial plaster 
made with the ammoniate of mercury over night. The 
next day this is to be removed and the following oint- 
ment to be applied : 



B. "subnit.,1 aa 5 j SS ; 7 

Vaselini, 3 V J a ^ SJ SS I 30 



M. 



Brocq advises a mercurial plaster during the night, 
bathing morning and evening with a 3 or 5 per cent, 
solution of bichloride of mercury, and wearing during the 
day oxide of zinc or bismuth ointment. 

The peroxide of hydrogen will cause a temporary dis- 
appearance of the pigmentation. In all cases where there 
is an underlying cause attention must be given first to it. 

Prognosis. Many of the symptomatic pigmentations 
disappear when the patient recovers his health. It is not 
well to promise a certain disappearance of the patches, as 
some of them are permanent. 

Chlorioblastosis is any anomaly of growth of the corium 
and subcutaneous connective tissue. (Auspitz.) 

Chorionitis. See Scleroderma. 

Chromidrosis (Krom-i 2 d-ros r i 2 s). Synonyms : Ephidro- 
sis tin eta ; Stearrhoea or Seborrhoea nigricans ; Pityriasis 
nigricans ; (Fr.) Cyanopathie cutanee, Melastearrhee. 



CHROMIDROSIS. 131 

This is a condition of the body in which the sweat has 
an abnormal color. Usually it affects only limited re- 
gions, especially the lower eyelids. The color is most 
commonly bine or bine-black. The subjects are most often 
hysterical women, and many of the cases are feigned. 

Besides the lower eyelids the upper ones may be 
affected. Next in frequency the colored sweat forms on 
some other part of the face, but it may occur on any por- 
tion of the body. Besides the blue or black color, cases 
of yellow, green, brown or even rosy color have been re- 
ported. A few men have exhibited the phenomenon. 
Hoffmann l reports a case of blue sweat of the scrotum of 
a man seventy-two years old, and White 2 has met with a 
case of yellow sweat in a man twenty years old. R. W. 
Taylor saw one case of apparently blue sweat that occurred 
in a man taking iodide of potassium, and was due to a re- 
action between the starch of his shirt and the iodine con- 
tained in the sweat. Constipation and nervous derange- 
ments are often found in the cases, and the chromidrosis 
has been noted to grow worse with increased constipation, 
and become better when that condition is removed ; to be 
more pronounced at menstrual periods, and to break out 
suddenly under emotional excitement. The skin may 
present no appearance of change except the discoloration, 
or it may have an evident deposit upon it. In either case 
the color can be removed by wiping with a little oil, or 
scraped off partially with the finger nail. 

Etiology. The cause of the disease is obscure. It 
has been thought to be due to the presence of colorless 
indican in the sweat, which becomes bine by oxidation. 
This accounts for a few cases at least. Most of the pa- 
tients are hysterical women. 

Diagnosis. The diagnosis is easy because the discolor- 
ation can be readily removed by an oiled cloth, while that 
of chromophy tosis does not so readily come off, and that 

1 Wien. med. Wochenschr. , 1873, xxiii., 291. 
2 Journ. Cutan. and Ven. Dis., 1884, ii., 293. 



132 DISEASES OF THE SKIN. 

of chloasma does not yield at all. Moreover, neither of 
these last two conditions exhibits a bine color. 

Treatment. The disease requires stimulation in its 
treatment, and good results have been reported from the 
nse of the following : x 



R. Ac. borici, gr. x; 2 

Ac. salicylici, gr. xv; 3 

Ungt. aquse rosse, 5J> 100 



M. 



The red siveat that occurs in the axillae more especially, 
and elsewhere eccasionally, is not a true chromidrosis, but 
is due to the growth of bacteria (micrococcus prodigiosus) 
upon the hair, as may readily be demonstrated under the 
microscope. The bacteria are sometimes present so abun- 
dantly as to encrust the hair. The same bacteria grown 
on culture-media are colorless, and it is supposed that the 
action of the sweat upon them determines their color. At 
times not only are the hair and skin stained red, but also 
the underclothing is deeply dyed. 

A mild parasiticide ointment or oil with the use of soap 
and water, or a simple borax solution, will cure the dis- 
eases just as in chromidrosis. 

Green sweat has been seen in workers in copper. 
Yellow sweat has been found associated with bacteria and 
without them. 

Chromophytosis 2 (Krom-o-fit-os'-iV). Synonyms : Pit- 
yriasis versicolor ; Tinea versicolor ; Chloasma ; Mycosis 
microsporina ; (Ger.) Kleien Flechte ; (Fr.) Pityriasis 
parasitaire. 

A vegetable parasitic disease, characterized by brown 
or cafe-au-lait colored, variously shaped and sized patches 
that occur chiefly upon the trunk. 

This disease is far more common than statistical tables 
show it to be, as it causes so little trouble that many peo- 
ple never think of applying for relief. It begins as a 

1 Van Harlingen : Handbook of Skin Diseases. 

2 The name of chromophytosis was proposed for this disease by Dr. 
F. P. Foster, and has been well received in New York, as it quite ac- 
curately defines the disease and brings it in line with trichophytosis. 



CHROMOPHYTOSIS. 133 

small yellowish point, which rapidly grows into a split- 
pea-sized lesion. Many new lesions appear and, these 
coalescing, patches form which may be so large as to 
occupy a great part of the chest or back. At first, when 
of small size, the patches are circular in shape, but as they 
grow larger they lose all definiteness of shape, though 
their edges are always sharply marked and sometimes 
raised. Annular patches sometimes form, and at other 
times there will be many more or less circular patches of 
sound skin in the midst of the diffused patch. The color 
is usually fawn or cafe-au-lait ; it may be brown or even 
black. The latter is reported only from tropical countries. 
In warm weather and in those who sweat profusely it is no 
uncommon thing to see the eruption present a pinkish hue, 
due to hyperemia of the skin. The edge of the patch 
may be somewhat raised, but the surface is not generally 
above that of the skin. It presents various appearances. 
At times it is smooth and feels greasy ; at times it is dry 
and covered with fine branny scales, while at times it looks 
rough, and, viewed in the proper light, it presents an ap- 
pearance resembling that of ichthyosis of mild grade. 
These appearances are dependent upon the amount of 
sweating, which, if profuse, will remove the scales, espe- 
cially if the clothing rubs upon the skin. The greasy 
feel is imparted by the oily sebaceous matter, always 
marked in the region of the sternum, where chromophy- 
tosis most often is located. Whatever may be the appar- 
ent condition of the surface, scraping with the nail will 
remove a good part of the disease, showing that it is lo- 
cated in the upper layers of the epidermis. These patches 
are located chiefly upon the anterior surface of the chest 
and upon the abdomen. The back is also quite often 
affected, but not so markedly as the chest. In very ex- 
tensive cases the arms and legs may show the disease and 
a few cases have been reported as occurring upon the face. 
C. W. Allen has pointed out that the disease is very often 
found concealed under the pubic hair. The rule is that 
the uncovered parts of the body are spared, and excep- 



134 DISEASES OF THE SKIN. 

tions to this are very rare. It is not symmetrical. The 
number of patches varies from a few to hundreds. 

The only subjective symptom is itching, and this is often 
absent, and seldom so bad as to cause the patient to seek 
relief on that account. Patients desire to be treated on 
account of the deformity, not the discomfort, of the disease. 

Etiology. The cause of the disease is the lodgement 
and growth in the corneous layer of the skin of a vege- 
table parasite, the microsporon furfur. Like all other 
parasites of its class, this one is incapable of growth on 
every skin, but does nourish especially upon the skin of 
one who sweats freely. That consumptives were thought 
to be especially prone to the disease is due to the fact that 
their chests are exposed to the physician more often than 
are those of any other class of patients. The disease is 
contagious, but its contagion is of low grade, and it is not 
common for it to take place even in such intimate rela- 
tions as obtain between husband and wife. Adults from 
twenty to forty years of age are the most common subjects, 
though children have had the disease. According to Bes- 
nier and Doyon, the disease is never seen in very old 
people. It occurs in all countries, but most often in hot 
climates. It attacks all classes and conditions of men, 
and shows no particular discrimination in regard to sex. 
Its growth is interrupted by malarial paroxysms, and it 
peels oif with the desquamation of scarlatina and measles. 

Pathology. The microsporon furfur is one of the 
most readily demonstrated of parasites. Place a few 
scales upon the slide, add a drop or two of liquor potassae, 
tease out the material a little, put on the cover-glass, and 
even with a low power the picture here represented will 
be seen (Fig. 13). It consists of heaps of conidia, which 
are larger than those of ringworm, with any quantity of 
interlacing mycelia running between them. Free conidia 
are scattered about in the field. The fungus grows in the 
upper layers of the epidermis. It has been asserted that 
there were two kinds of fungus, one brown and the other 
pale red, each of which produces its own colored eruption. 



CHR OMOPHYTOSIS. 



135 



In 1896 T. Spietschka succeeded in making a pure cul- 
ture of the fungus, inoculating an individual with it, re- 
producing the disease and making pure cultures from it. 
Diagnosis. If one remembers the characteristic fea- 
tures of the disease, yellow or cafe-au-lait, scaly patches, 
that can be partly scraped away and are located chiefly 
upon the chest, little difficulty can arise in diagnosis. An 
appeal to the microscope will decide any doubtful ques- 
tion. Chloasma is not scaly and cannot be scraped off 



Fig. 13. 




IMicrosporon furfur. (After Kaposi.) 

from the skin. Leucoderma is an absence of pigment with 
a hyper-pigmentation about it that comes up to the white 
spot with a concave border and is not scaly. A fading 
erythematous syphilide occurs not in patches, but in isolated, 
round macules that are neither scaly nor itchy, that are 
usually most numerous over the abdomen and sides of the 
chest, and that are very often found as a disseminated 
eruption occurring upon the face as well as the trunk. 



136 DISEASES OF THE SKIN. 

Erythrasma is not so scaly and occurs only in or about 
the joints. Its parasite is much smaller than that of 
chromophytosis. 

Treatment. Anything that will cause the removal of 
the upper layers of the epidermis will cure chromophyto- 
sis when present only to slight degree. But it is best for 
safety to use a parasiticide. One of the pleasantest ways 
of curing the disease is to have the patient scrub his skin 
thoroughly with soap and water , preferably soft-soap, and 
then dab on, twice a day, a saturated solution of hyposul- 
phite of soda. Sulphurous acid, pure or dilute, is a 
prompt remedy. Vleminckx's solution, one to three or 
six parts of water ; bichloride of mercury, two or three 
grains to the ounce ; sulphur ointment rubbed in thor- 
oughly, and tincture of veratrum viride are efficacious. 
The danger of systemic poisoning by either the bichloride 
of mercury or the veratrum viride should deter us from 
using these remedies in extensive cases. Unna l recom- 
mends : 

R. Tinct. rhei aquosae, j -- M 

(jrlycerini, J ^ 

Brocq. gives the following : 

R. Acid, salicylici, 2-3 parts. 

Sulphur, prsecip., 10-15 " 

Lanolini, 70 

Vaselini, 18 " M. 

Chrysarobin, naphtol, boric acid and resorcin all are 
good. If the disease is very limited it can be surely and 
speedily destroyed by painting the spot with tincture of 
iodine. 

There is only one point to be borne in mind in using 
any of these remedies, and that is that they must be 
thoroughly used and continued for a time even after the 
last trace of the fungus seems to have been removed. If 
one spore is left behind the disease is liable to return. 

1 Vierteljahrschr. Derm. u. Syph., 1880, vii., 166. 



CLAWS. 137 

Special care must be given to the cure of the disease in 
the pubic region. Relapses are common, as the patient's 
skin is susceptible to the lodgement of the fungus. 

Clastothrix. See Trichorrhexis nodosa. 

Clavus (Kla'vu 3 s). Synonyms : (Fr.) Cor ; (Ger.) 
Leichdorn, Huhnerauge ; Corn. 

Symptoms. Corns are hyperplasias of the corneous 
layers of the skin due to pressure and differing from cal- 
luses in haying a central core that grows down toward 
the coriuni. They occur usually upon the toes, either oyer 
prominent joints, where they form hard corns, or between 
the toes, where, on account of being kept moist, they form 
soft corns. They are usually conical in shape and slightly 
projecting. Unless pared down they become painful by 
being pressed into the cutis. They are sometimes spon- 
taneously painful on the approach of wet weather on ac- 
count of their being hygroscopic. They may suppurate. 
They may occur upon the palms ; I have seen several 
cases in tennis players. The soles are sometimes affected 
with them, and then walking is rendered very painful. 

Treatment. The best treatment for corns is to wear 
well-fitting boots and shoes, which must not be too large 
or too small. Pointed-toed shoes are specially apt to 
cause corns. The corn may be removed by the use of a 
salicylic acid plaster, or by Vigier's preparation, now 
sold in all the shops under the name of Hebra's Corn 
Remedy, which is composed of — 

R 



Ac. salicylici, 


gr. xy. 


Ext. cannabis indicse, 


gr. viij. 


Alcoholis, 


n\,xv. 


Etheris, 


TT^xl. 


Collodion flex., 


TT^ lxxv. 



M, 

which is to be painted on three times a day for a week ; 
then the feet are to be soaked in hot water, and the corn 
picked out. They may also be cut out, but the operation 
is at times dangerous, especially in old people. Resorcin 
plaster of ten per cent, strength worn for some days will 



138 DISEASES OF THE SKIN. 

remove corns. Crocker recommends for soft corns careful 
daily ablution with soap and water, painting on them 
spirits of camphor at night and wearing wool between the 
toes during the day. But unless well-made shoes are 
worn 7 the corns will be sure to return. Corns on the hands 
may be removed with salicylic acid, or scraped out with 
the dermal curette. 

Clavus Syphiliticus. Under this title Lewin 1 describes 
certain lesions that he regards as being syphilitic. They 
are horny elevated growths that occur upon the hands and 
feet, and are sometimes surmounted by a delicate scaly 
crown, and sometimes covered with scales. They are 
from pinhead to lentil sized, circular, oval or oblong 
in shape ; flat or concave on top, but never convex, and 
appear as if wedged into the skin. At first they are pale 
red and soft, but later they become yellowish horn-color 
and hard. They are usually on the palms of the hands, 
but may be on the soles of the feet, as well as upon all 
surfaces of the fingers and toes. There is no pain caused 
by them. There may be some itching. The lesions are 
met with in both sexes, and occur early in the disease, 
and often symmetrically. 

Cnidosis. See Urticaria. 

Cold Sore. See Herpes facialis. 

Colloid degeneration of the skin. Synonyms : Colloid 
milium ; (Ger.) Hyalom der Haut ; (Fr.) Hyalome 
cutan<3. 

Symptoms. This is a very rare disease of the skin 
that occurs most often on the upper part of the face in 
the form of disseminated or grouped, discrete, trans- 
parent, shining, rounded, lemon-yellow elevations of the 
skin. Though they look as though they were vesicles, 
they do not contain fluid, and when pricked give exit to 
only a small amount of gelatinous substance and a drop 
or two of blood. They are resistant to the touch. The 

1 Arch. Derm u. Syph., 1893, xxv., 3. 



COMEDO. 139 

course of the disease is slow. It is capable of spontaneous 
disappearance by absorption or inflammation, leaving an 
ill-defined mark on the skin. It affects both sexes. The 
youngest patient so far reported was fifteen years old. 
There are no subjective symptoms, and the general health 
is good. 

Diagnosis. It differs from xanthoma in the trans- 
parency and shining appearance of the lesions and in 
their lemon-yellow color. In xanthoma the lesions are 
soft and of a dull yellow. . In kydroeystoma the lesions 
are more crystalline in appearance, and when pricked a 
drop of pure fluid escapes from them. In adenoma se- 
baceum the lesions are markedly vascular in places. 

Treatment consists in removing them by the curette 
or electrolysis. 

Comedo (Ko 2 m'e 2 d-o).. Synonyms : Acne punctata, 
Acne follicularis ; (Fr.) Comedon, Acne punctuee, Tanne ; 
(Ger.) Mitesser, Hautwurmer ; Grubs, Fleshworms, Black- 
heads. 

A comedo is a collection of inspissated sebaceous matter 
retained in a pilo-sebaceous gland, whose mouth is closed 
by a brown or black-topped plug of extraneous matter, 
and appears as a pin-point to a pinhead, slightly ele- 
vated, conical papule in the skin. 

Symptoms. Comedones are met with most often upon 
the face, ears, back, and shoulders, and occasionally, but 
much more rarely, on other parts of the body. Wher- 
ever met with they present the characteristics indicated 
in the definition just given. They are unaccompanied by 
inflammatory symptoms. Just as soon as inflammation is 
caused by their presence they are converted into acne 
lesions — a change that they very commonly undergo. 
Usually they are scattered about irregularly ; sometimes 
they are grouped in certain regions. They are single 
lesions in the vast majority of cases, and being pressed 
between the thumb-nails they are readily expressed in the 
form either of an ovoid mass or more commonly as a fili- 



140 DISEASES OF THE SKIN. 

form or worm-like mass that may be a half-inch or more in 
length, and has a black head that obtains for them the pop- 
ular name of " flesh-worms." Very exceptionally they 
are double, lateral pressure squeezing out a filiform mass 
with a black head at both ends, if such an expression is 
allowable. There may be but few, or there may be hun- 
dreds of them, so that the face looks as if full of grains of 
gunpowder. The largest are found in the ears and on 
the back. They give rise to no subjective symptoms. 
Seborrhoea oleosa is frequently a marked complication. 

In children they are more apt to be grouped, and, ac- 
cording to Crocker, to appear on the forehead and occiput 
of boys, the temples in girls and the cheeks in infants. 
The scalp, too, is in them the seat of the disease. Acne 
may follow them. 

Etiology. All that has been said as to the causes of 
acne applies with equal force to comedones and need not 
be repeated here. We would only add that Unna does 
not accept the commonly received doctrine that the black 
head and the clogging of the follicle are largely due to 
extraneous matter, but teaches l that they are due to the 
corneous layer of the skin being abnormally firm and 
preventing the escape of the follicle contents by growing 
over its mouth. The black color he believes to be anal- 
ogous to the coloration of horns in cattle. He calls at- 
tention to the fact that comedones are more frequent in 
chlorotic girls than in coal-heavers. 

It is quite certain that many cases of comedones are 
directly due to dirt or other foreign matters stopping up 
the follicles. This is supposed to be especially the case 
in children. Colcott Fox 2 says that in them the come- 
dones are found most often in the spring-time and disap- 
pear in the winter. The youngest case in a child is one 
at twelve months. 3 

Pathology. The pathology of the affection is the 
same as that of acne without the evidence of inflammation. 

1 Virehow' s Archiv, 1880, lxxxii., 175. 
2 Lancet, 1888, L, 665. 3 Crocker: Lancet, 1884, i., 704. 



COMEDO. 



141 



We find many varieties of micro-organisms in comedones. 
The demodex fotticulorum, a harmless parasite, is very often 
found in the plugs of sebaceous matter. This is long and 
worm-like, with a head ; a thorax with four pairs of short, 
conical, three-jointed feet, with minute claw-like extremi- 



Fig. 14. 




Dernodex folliculorum. (After Kuciiexmeister. 



ties and a long tail-like abdomen, which tapers off into a 
blunt and rounded point. (Fig. 14.) 

Von During 1 has endeavored to show that the double 
comedo is always an acquired formation, and is the result 
of a destructive process between the ducts of two neigh- 
boring glands, so that the two ducts become one, and that 
the destructive process has affected only one gland, while 



1 Monatshefte f. prakt. Dermat. 3/ 1888, vii., 401. 



142 



DISEASES OF THE SKIN. 



the other one is still active enough to produce the comedo 
plug. 

Diagnosis. There is little difficulty in recognizing 
the disorder. Powder grains in the skin are under the 
skin and cannot be squeezed out. 




■11 

Piffard's comedo-extractors. 

Treatment. The same constitutional conditions being 
met with in comedones as in acne, we need not repeat 
here what was said there in regard to their general treat- 
ment. 

The local treatment consists in pressing out the come- 
dones and stimulating the skin to a more healthy action. 
There is little use in doing the first without the second, 
as the comedo would be sure to re-form. The comedones 
come out most readily after the free use of soap and warm 
water. Then they may be pressed out between the 
thumb-nails,, or by means of an old Avatch key, whose 

Fig. 16. 



Fox's comedo-scoop. 

sharp edges have been worn down ; or by means of either 
of the comedo-pressers of Piffard (Fig. 1 5), or the comedo- 
scoop of Fox (Fig. 16). With some practice they may 
be removed by pressing the back of a small dermal curette 
against one side of the follicle mouth and making a quick 
turn of the end about them. Violent attempts at removal 
should not be made, as they may cause inflammation on 



COBXU CUTANEUM. 143 

account of too much irritation. If the comedo does not 
come out readily, wait until another time. 

Frictions with green or soft soap and water are excel- 
lent as a stimulating remedy, care being taken not to set 
up too much reaction. Hardaway recommends : 



R. Saponisoliv^epreparat.,-1 -- *. 16 

Alcoholis, 



M. 



Aqua? rosre, 5 Y J 5 100 

To be rubbed in with a piece of dampened flannel 
every night. He regards the use of sulphur prepara- 
tions as tending to cause comedones and hence objection- 
able. Alcoholic and astringent lotions of boric acid, 
alum or zinc are useful. 

Sulphur and most of the preparations given under 
acne have their advocates here. 

The best prophylactic measure is the daily washing of 
the face with soap and water. 

Condyloma. See Verruca and Syphilis. 

Congelatio. See Dermatitis calorica. 

Corn. See Clavus. 

Cornu Cutaneum vel Humanum. Synonyms : (Fr.) 
Corne de la peau ; (Ger.) Hauthorn ; Cutaneous horn. 

This is a rare disease of the skin, in which there grows 
a horn-like excrescence resembling, often in a most strik- 
ing manner, an animal's horn. These vary greatly as to 
size. They may attain the length of a foot and a diam- 
eter of fourteen inches at the base, and are usually single, 
but may be multiple. They may be straight, but usually 
are bent or twisted ; they may be laminated, striated or 
fibrillated ; they may be yellowish, dirty gray, green, 
brown or black ; they are solid and hard, but not smooth 
and shining like animals' horns often are ; and they have 
rounded or truncated ends. They are not painful unless 
pressed on. When torn or knocked off they expose a 
raw and bleeding surface. Sometimes they fall sponta- 
neously or as the result of some inflammatory process. 



144 DISEASES OF THE SKIN. 

Most of them occur upon the head, nose, face, or scalp. 
They may occur elsewhere, as upon the extremities or 
male genitals. Their bases may become the site of epi- 
thelioma. 

There is little known about their etiology. They may 
occur at any age and in either sex. They seem to be 
warty growths that have undergone corneous transforma- 
tion. 

Treatment. The treatment consists in tearing them 
off, under an anaesthetic if large, curetting the base and 
applying a caustic agent, such as a chloride of zinc paste 
or pyrogallic acid. 

Couperose. See Rosacea. 

Crasses Parasitaires. See Chromophytosis. 

Crusta Lactea. See Eczema. 

Cutis Anserina, or Goose-flesh, is that condition of the 
skin in which, on account of the action of cold causing a 
contraction of the arrectores pilorum muscles and eleva- 
tion of the hair follicles, it feels rough and looks as if 
studded over with minute papules. It is a fugitive affair, 
therein differing from keratosis pilaris, which, though re- 
sembling it, is constant. 

Cutis Pendula. See Dermatolysis. 

Cutis Tensa Chronica. See Scleroderma. 

Cutis TJnctuosa. See Seborrhoea. 

Cyanosis (Si-a 2 n-os'i 2 s) is a bluish coloration of the skin 
from defective aeration of the blood, either temporary, as 
in asphyxia, collapse, etc., or permanent, as in the subject 
of some malformation of the heart, especially persistent 
patency of the foramen ovale. 1 

Cysticercus Cellulosae Cutis. At times the larvse of the 
tapeworm become lodged in the subcutaneous tissues and 
produce movable, painless, round or oval, pea- or cherry- 
sized tumors, with the skin raised over them. They are 

1 Foster' s Encyclopaedic Medical Dictionary. 



DEEMATALGIA. 145 

smooth, firm, and elastic. The larger ones may feel like 
wens. After about eight months (Cobbold) the animals 
die, and the tumors shrivel up and become hard nodules, 
or they may be absorbed. They simulate gummas, lipo- 
mas, sarcomas, carcinomas, and sebaceous cysts. In a 
doubtful case excision or puncture of one of the tumors 
will show us under the microscope either one of the larvae 
curled up in its shell, as it were, or the hooklets in the 
fluid that escapes. 

Cysto-adenoma is an adenoma containing cysts. 

Dandriff or Dandruff. See Seborrhoea. 

Dartre Farineuse, Furfuracee, or Volante. Old terms 
for Pityriasis and Eczema. 

Dartre Rongeante. See Lupus vulgaris. 

Dartrous Diathesis. This term, though still used by 
French writers, is of very indefinite meaning and has been 
dropped by their latest author, Broeq. Dunglison defines 
it as a a peculiar state of health, which renders its subject 
liable to general eruptions of different forms, which are 
always met with in the young, are symmetrical and con- 
trolled by arsenic." It is supposed to be the underlying 
cause of eczema, herpes, seborrhoea, psoriasis and not a few 
other diseases. 

Defluvium Capillorum. See Alopecia. 
Defcedatio Unguium. See Nails, degeneration of. 
Delhi Boil. See Aleppo boil. 

Dermatalgia (Du 5 rnL-a 2 t-a 2 l'ji 2 -a 3 ). Synonyms : (Fr.) 
Dermalgie ; (Ger.) Hautschmerz ; Hautnervenschmerz ; 
Neuralgia or rheumatism of the skin. 

By this term is meant spontaneous pain in the skin, 
without any appreciable alteration of the same. The pain 
is variously described by patients as boring, pricking or 
burning, or numbness or coldness may be complained of. 
It is constant or intermittent in character and sometimes 
10 



146 DISEASES OF THE SKIN. 

so severe as to be agonizing. It is generally sharply lo- 
cated in a certain region, but it may be general. The hairy 
parts are those most often affected, as the scalp. The legs 
and back, and palms and soles are also not infrequently in- 
volved, as may be any part. Hyperesthesia or anaesthesia 
may be present at the same time. Deep pressure may or 
may not relieve it. It disappears of itself after weeks or 
months. 

Etiology. It is a neurosis that may be idiopathic or 
symptomatic. The idiopathic form is rare, and its etiology 
obscure. The symptomatic form occurs in dyspepsia, loco- 
motor ataxia, rheumatism, syphilis, malaria, diabetes, hys- 
teria, chlorosis, and after zoster. According to Hyde, it 
may be a sign of the approaching menopause. The ma- 
jority of its subjects are women. 

Diagnosis. Dermatalgia differs from neuralgia in 
being more superficial and in being accompanied by hyper- 
esthesia. It differs from hyperesthesia in being a spon- 
taneous pain, while the latter is pain only upon contact. 

Treatment. If we can remove the underlying cause 
we shall cure the trouble, so our remedies should be first 
addressed to it. In any case the patient demands some- 
thing to relieve the pain. In the way of internal remedies 
we can use salicylate of soda, quinine, antipyrin, phena- 
cetin, some form of opium, hyoscyamus, valerian and other 
like drugs. Externally, relief may be obtained by galvan- 
ism, blistering, a mustard leaf over the center from which 
emanates the nerve (Crocker), hot or cold water in a rubber 
water-bag, either alone or alternately ; rubbing in Squibb's 
oleate of mercury or morphine, menthol pencil, chloroform 
liniment, tincture of aconite and the like. 

Dermatitis (Du 5 rm-a 2 t-i /2 tis). This word means simply 
inflammation of the skin, and would, therefore, cover all 
diseases of the skin that are of inflammatory nature. But 
it is applied to those diseases of the integument that are 
simple inflammations and due to the action of external 
irritants. They are all marked by redness, swelling and 
heat. The name dermatitis, with a qualifying adjective, 



DERMATITIS CALORICA. 147 

is also applied to diseases other than those in this section, 
as will be seen further on. 

Dermatitis, Blastomycetic. Under the name of pseud- 
lupus or blastonryeetic dermatitis, T. C. Gilchrist and W. 
R. Stokes l describe a disease that has been recognized for a 
long time and regarded as a lupus, or at least a scrofulo- 
derm. The disease begins in early adult life as a small 
pimple that becomes purulent, and slowly spreads peri- 
pherally while forming an atrophic cicatrix in the older 
central parts. Xew lesions appear on different parts of the 
body and spread slowly. Some of these heal of themselves 
after lasting a year or more. Clinically the appearances are 
those of lupus, but there is no suggestion of tuberculosis 
in the patient or his antecedents. Microscopically the 
sections show budding blastomycetes. 

Dermatitis Bullosa. See Epidermolysis. 

Dermatitis Calorica is the inflammation of the skin pro- 
duced by heat or cold and divides itself naturally into 
two divisions, viz.: d. ambustionis and d. congelationis. 

Dermatitis ambustionis is the effect of heat upon the 
skin, the source of the same being either natural, as from 
the sun, or artificial. According to the intensity and pro- 
longed action of the heat and the resistance of the skin 
will be the damage inflicted on the skin. A slight de- 
gree of heat gives rise to a passing erythema. Burns are 
due to a greater amount of heat and are described for 
convenience as being of three degrees. In the first de- 
gree the skin is reddened, hot and somewhat swollen ; in 
the second the damage is greater and we have the pro- 
duction of vesicles and bulla? ; and in the third there is 
complete destruction of the skin followed by gangrene. 
There is always considerable pain with any burn and if 
of great extent we have rise of temperature and shock. 
Extensive burns may be dangerous to life even if not of 
very high degree, and burns involving one-half the cu- 

1 Johns Hopkins Rep., 1897, viii., 46, and Journ. Cutan. and Gen.- 
Urin. Dis., 1897, xv., 393. 



148 DISEASES OF THE SKIN. 

taneous surface are generally fatal. The cause of death 
in such cases is uncertain. One theory, as put forth by 
Lustgarten, 1 is that it is due to a toxin developed by the 
lodgement of micro-organisms of putrefaction upon the 
eschar, probably a ptomaine similar to muscarin. Some 
of the other theories are nerve-shock, ulcerations of di- 
gestive tract, nephritis, decomposition of the red blood- 
globules ; but no one of these is satisfactory in all cases. 

Treatment. The treatment of severe burns com- 
monly falls into the hands of the surgeons. In simple 
burns the pain may be relieved by painting them with a 
five to ten per cent, solution of cocaine, and then apply- 
ing Carron oil, consisting of equal parts of linseed oil 
and lime-water, to which may be added 5 per cent, of 
carbolic acid, by means of saturating absorbent cotton in 
it and then covering it with impermeable rubber tissue. 
This forms an admirable dressing that may be left on for 
several days, if care is taken to disinfect the part thor- 
oughly before applying it. If this is not at hand the 
part should be dusted thickly with flour or cornstarch 
until it is procured. Or the burns may be covered with 
a varnish of linseed oil and wax, containing 5 per cent, 
of salicylic acid. Or they may be powdered with bicar- 
bonate of soda or any of the antiseptic powders. Deep 
and extensive burns must be treated on surgical and 
strictly antiseptic principles. Lustgarten, in the paper 
referred to, recommends the administration of atropine as 
a physiological antagonist to the ptomaine, the removal of 
necrotic portions of skin and dressing the wound with 
carbonate of magnesia, 1 part, and oleum rusci, 2 parts. 
All cases of any magnitude demand absolute rest in bed. 
The continuous water-bath of Hebra is excellent where 
it can be had. 

In sunburn the application of cold cream and a dusting 
powder is usually sufficient. As a preventative the skin 
may be anointed with the grease paint used by actors, pref- 

!Med. Eec, 1891, xl. ; 152. 



DERMATITIS CALORIC A. 149 

erably one of brown color. Or a calamine lotion may 
be used freely. 

Dermatitis congelationis or "frostbite" is the action of 
cold upon the skin. Like heat, cold produces varying 
degress of damage to the skin ; if not very intense, the 
effect is an erythema — " erythema pernio/' " chilblain " 
— which is passing. These are seen upon the hands, feet, 
and face as bluish or purplish-red, circumscribed patches, 
which are cool to the touch, but are accompanied by a 
feeling of heat, smarting, or burning, both while forming 
and Avhen the parts again become warmed. To those pre- 
disposed to chilblains, dampness accompanied by only 
very moderately cool temperature is sufficient to produce 
them. Hutchinson speaks of the chilblain diathesis to 
indicate the condition found in these people. Their circu- 
lation is poor, and they are anaemic. Greater degrees of 
cold at first cause the parts to look white, dead, and 
wrinkled. AVhen the cold is lessened redness and swel- 
ling supervene. Longer exposure may produce bullae and 
vesicles, or gangrene, either on account of prolonged 
anaemia or inflammatory reaction from too sudden warm- 
ing. Fingers, toes, nose, or ears may be lost in conse- 
quence, mortification setting in. Death may result from 
septicaemia. 

Treatment. The best preventive treatment of chil- 
blains is the wearing of woollen coverings to the af- 
fected parts, and endeavoring to improve the general 
health of the patient and to quicken his circulation. To 
the latter end we may use warm foot-baths, containing 
salt, at night, followed by frictions with alcohol. When 
they occur stimulation is necessary, for which we may use 
iodine, either in tincture or ointment ; or equal parts of 
camphor and belladonna liniment ; or — 



R. 01. cajiputi, \ 

Liq. ammon. fort., / 



;Ul 



oy 



Sapo. liniment, co., giij ; 100 M. 

or simple frictions. Care should be taken in severe frost- 



150 DISEASES OF THE SKIN. 

bites not to allow the parts to become warm too rapidly, 
and nothing is better than nibbing them with snow, if 
that can be obtained, while the patient is kept in a cool 
room. When sloughing or ulceration is begun it must be 
treated on surgical principles. 

Dermatitis Contusiformis. See Erythema nodosum. 

Dermatitis Epidemic a. Under this name Say ill * has 
reported the occurrence, in Paddington Infirmary, of a 
number of cases of an apparently contagious disease of the 
skin, that began either as a discrete papular eruption, or 
as erythematous blotches like erythema nodosum or papil- 
losum, or as small, flat papules enlarging at the periphery 
and spreading like ringworm. This stage lasted three to 
eight days. It was followed by the second stage, which 
was one of exudation or desquamation, and lasted three 
to eight weeks. However the disease began, the lesions 
soon ran together and formed a crimson surface of thick- 
ened and indurated skin, continually shedding its cuticle 
in scales or flakes of various sizes, sometimes mingled with 
drier exudation. In the second stage it assumed either a 
moist type, like eczema madidans, or a dry one like pity- 
riasis rubra. About two-thirds of the cases were of the 
moist variety, and almost all at some period showed slight 
moisture, either in the flexures of the joints or behind the 
ears. Continuous exfoliation was present in all the cases. 

The third stage was one of subsidence. By degrees 
the inflammation lessened, leaving an indurated, thick- 
ened skin, with polished brown appearance, which was 
sometimes raw, or parchment-like, smooth and shiny, or 
cracked, or purpuric, especially in aged people. 

The disease began most often in the skin-folds of the 
face and upper extremities, -and involved either the whole 
body or limited areas. It generally spread by continuity. 
The hair and nails were all shed. 

The constitutional symptoms were anorexia and pros- 
tration. There was either no change in the body-tem- 

1 Brit. Journ. Dermat., 1892, iv. } 35. 



DERMATITIS EXFOLIATIVA. 151 

perature or a slight rise in the evening during the height 
of the disease. Itching and burning were marked, and 
there was considerable suffering experienced in those 
cases in which the epidermis was shed. Relapses were 
frequent. Albuminuria was found in half of the cases, 
and death occurred in about 12 4-5 per cent, of the cases. 

More men than women were attacked, and advanced age 
predisposed to it. A specific micro-organism is thought 
to have been found in it. 

Clinically these cases resemble dermatitis exfoliativa, 
an instance of the contagion of which I have once met 
with. Its proper place has not been determined as yet. 

Dermatitis Exfoliativa, Synonyms ; Pityriasis rubra 
(Devergie and Hebra) ; Eczema foliaceum seu exfoliati- 
vum ; (Fr.) Dermatite exfoliatrice ou exfoliative general- 
isee, Herpetide exfoliative, Erythrodermie exfoliante. 

An inflammatory disease of the skin involving the 
whole cutaneous surface, and characterized by redness, 
dryness, and abundant desquamation. 

The terms dermatitis exfoliativa and pityriasis rubra 
are used interchangeably by most authorities of the pres- 
ent time. If one reads the description of pityriasis rubra, 
as given by Hebra, and of dermatitis exfoliativa, as given 
by Wilson, he will find that the chief difference between 
them is in prognosis, the first being spoken of as uni- 
formly fatal, and the second as tending to recovery in 
many instances. Further, there are not a few cases of 
general exfoliating dermatitis that follow psoriasis, 
eczema, pemphigus foliaceus, and lichen ruber, that pre- 
sent symptoms identical with those of dermatitis exfoli- 
ativa, without antecedent disease. It seems justifiable, 
therefore, to divide dermatitis exfoliativa into two vari- 
eties, namely, a primary and a secondary. 

1. Primary Dermatitis exfoliativa or Pityriasis rubra of 
Hebra. 

Symptoms. This disease begins as one or more ery- 
thematous patches in the folds of the joints, upon the 



152 DISEASES OF THE SKIN. 

upper part of the chest or elsewhere, and these patches 
gradually enlarge. At the same time new patches de- 
velop, and, increasing in size, join the original ones. In 
this way the whole surface may become red within three 
days, or a month or more may elapse before the whole 
surface is implicated. The palms and soles may be un- 
affected for days or weeks. The skin is dry and of a 
bright red at first, without thickening and infiltration, 
the redness lessening and leaving a yellow stain on pres- 
sure. In a few days, say from six to twelve, scaling be- 
gins and the skin becomes of a darker red ; it may even 
become violaceous. The scales may be large, thin, gray- 
ish, attached at their upper border and loose elsewhere, 
being turned up at their edges. They may be small and 
adherent in the center. The amount of scaling is so 
great that handfuls of scales may be gathered from the 
bed after a night's rest. After a few weeks the epidermis 
is raised and shed from the hands and soles in the form 
of a continuous sheet, sometimes forming a complete cast 
of the part. There is a marked enlargement of the glands 
in the groin, so that the whole packet of glands stands out 
prominently against the red skin. The disease is chronic 
and the scaling constant, though marked with exacerba- 
tions. After lasting some time there is a certain amount 
of infiltration of the skin and it seems to grow too small 
for the body and looks stretched and shiny in places. 
Thus are produced ectropion and a puckered condition of 
the mouth. We may also find cracking about the joints 
and moisture in these regions. Furuncles, bullae, or pus- 
tules may complicate matters. The hair may be shed 
from all parts and the nails become raised from their beds 
and shed. The mucous membranes participate in the dis- 
turbance, the tongue becomes markedly red, the lips 
cracked and the nasal secretions are increased. With the 
ectropion there is conjunctivitis. 

The disease begins, in some cases, with a chill, followed 
by a fever that may rise to 104° F. Fever is present in 
all cases during the early period and may continue through- 



DERMA TITIS EXFOLIA TIVA. 153 

out. It is sometimes continuous, with evening exacerba- 
tions ; at other times it is only at night. Diarrhoea often 
is met with, and there may be vomiting, albuminuria, and 
pulmonary congestion. The patient complains of a feel- 
ing of chilliness and of pain, tenderness, stinging, burning, 
or tingling of the skin. There is usually no itching. The 
sensibility of the skin is preserved and the secretion of 
sweat may be normal, or lessened, or increased. The 
duration is very variable. Recovery may take place in 
six months or a year, or the course may be chronic, the 
patient dying either in a few months or after years by a 
gradual marasmus, though the end is usually hastened by 
pulmonary complications. 

Cases of localized dermatitis exfoliativa have been re- 
ported, but they are rare. The tendency is for the disease 
to become general, though it may take years to do so. 
Cases of a recurrent type have been met with. 

Etiology. We know very little about the causes of 
the disease. It is a disease of adults and more common in 
men than in women. It may occur in children. It has 
been thought to be predisposed to by alcoholism, gout, and 
rheumatism. An attempt has been made to trace a rela- 
tionship between it and general tuberculosis. There may 
be a history of scaling skin diseases in the family. At 
present we cannot speak with any certainty as to its eti- 
ology. 

2. Secondary Dermatitis Exfoliativa. A condition of 
the skin exactly resembling the primary form is seen from 
time to time to follow upon or develop from a psoriasis, 
eczema, pemphigus foliaceus, and lichen ruber. I have 
seen one case follow lichen planus. The too vigorous use 
of chrysarobin has been known to be followed by it. 
These cases diifer from the primary form only in their 
antecedent skin disease. Once developed they run the 
same course as the primary form, either becoming well 
quickly, or falling into a chronic state from which recovery 
may or may not take place. The prognosis is, however, 
much better in the secondary than in the primary form* 



154 DISEASES OF THE SKIN. 

Crocker states that the disease may occur in children, 
though it is very rare. In them it runs a more acute 
course and is attended by severe constitutional symptoms. 
It is usually of the secondary variety. 

Pathology. Histological examination shows that the 
disease is a dermatitis, quite superficial at first, but when 
it has lasted some time the whole depth of the skin is 
involved and eventually there is new connective-tissue 
formation, which subsequently undergoes cicatricial con- 
traction, with abundant pigmentation, hyperplasia of the 
elastic fiber bundles, and obliteration of the skin append- 
ages. (Crocker.) 

Diagnosis. When the features of the disease, as laid 
down in the definition, are remembered, there should be 
no difficulty in recognizing it. No other disease involves 
the whole surface in a uniform dry and scaling redness. 
It differs from psoriasis in being universal, in an entire 
absence of thick, silvery-white scales and in leaving a 
smooth, red surface when its papery scales are removed. 
Should it be secondary to a psoriasis, there will be no 
difficulty in obtaining a history of that disease. It differs 
from eczema in being a dry disease, with little infiltration, 
in its large papery scales, and in itching but slightly. 
Eczema may be almost universal, but some places are apt 
to be spared ; there is always moisture of a sticky sort 
present somewhere or a history of the same ; its scales are 
small and its itching intense. It differs from pemphigus 
foliaceus in an absence of flaccid bullae. It differs from 
lichen ruber in an entire absence of papules and in the 
whole course of the disease. All these diseases may be 
general, but it is exceedingly rare for them to become uni- 
versal and it is always possible to obtain a history of their 
having been present at some time in a case of secondary 
dermatitis exfoliativa. It is hardly likely that scarlatina 
could be confounded with dermatitis. A few days' watch- 
ing would in any event decide the question. 

Treatment. The results of treatment of this disease 
leave much to be desired. Many internal and external 



DERMATITIS EXFOLIATIVA. 155 

remedies have been tried, but they all are of very uncer- 
tain value. There is no doubt that the patient is most 
comfortable when the skin is well oiled, and vaseline of 
good quality answers well for this purpose. The general 
health is to be watched over, iron and quinine adminis- 
tered, and care exercised to preserve the strength by judi- 
cious feeding without stimulation. Diuretics may be given 
with the idea of relieving the congestion of the skin. Car- 
bolic acid has been recommended, but in my hands proved 
worse than useless in one case. Pilocarpin, or jaborandi, 
is recommended by Hardaway in acute cases. Arsenic 
should not be given till late in the disease, if at all. 
Crocker recommends enveloping the body in calamine 
lotion, and giving bicarbonate of potash every four hours 
in twenty-grain doses, with twelve grains of citric acid 
and three to five grains of quinine, the whole taken while 
effervescing. Sherwell has reported several cases cured 
by the continuous use of linseed oil, both internally and 
externally. The patient is to chew or take in milk several 
ounces of flaxseed in twenty-four hours. He is to be 
kept in bed with a rubber sheet under him, and to be 
saturated, as it were, in crude linseed oil. If the oil is 
not used abundantly it is worse than useless. This plan 
of treatment worked admirably in one of my cases. Thy- 
roid extract has proved helpful in some cases. In one of 
mine it aggravated the disease, and the patient made a 
good recovery after it was stopped, and she was treated 
with vaseline, soda baths, and careful feeding. 

Dermatitis Exfoliativa Neonatorum is a disease of new- 
born children, first described by Ritter von Rittershain, 1 
and said by him to be quite often seen in the foundling 
asylums of Prague. 

Symptoms. It begins at the mouth as an erythema, 
and thence spreads to the trunk and extremities. Then 
the epidermis raises itself from the cutis, rumples, and 
spontaneously exfoliates in large folds leaving a dry skin, 

1 Archiv f. Kinderheilkunde, 1880, i., 53. 



156 DISEASES OF THE SKltf. 

or there may be exudation under the epidermis. It be- 
gins usually between the second and fifth week of life 
and lasts seven or eight days. Relapses may occur. 
There is no fever, nor digestive disturbances. Furuncles, 
abscesses, or phlegmonous infiltration, with gangrenous 
destruction, may follow. Recovery takes place in about 
half the cases. It is supposed to be a pysemic condition 
of the skin. 

Treatment. Alkaline lotions will prove beneficial in 
the early stage. Later, a protecting ointment, such as 
that of oxide of zinc, or simple vaseline, followed by corn- 
starch, will be indicated. 

Dermatite Exfoliative Aigue Benigne. See Erythema 
scar latini forme. 

Dermatitis Gangrenosa or Sphaceloderma. Gangrene 
of the skin may be due to a great variety of causes. Many 
cases are due to purely local causes, such as burns, bruises, 
compression, chemical action, and the like. It is seen in 
the course of diabetes, albuminuria, and some cardiac dis- 
eases ; with degenerative changes taking place in the vas- 
cular walls of arteries, or plugging of their lumen ; and 
in connection with other skin diseases, as carbuncle. Be- 
sides these we have a group of little-understood cases of 
gangrene, due, apparently, to nervous influences, and oc- 
curring in connection with diseases of the nervous sys- 
tem. These may occur anywhere, and may be superficial 
or deep. They behave like surgical gangrene, and are to 
be treated on the same principles. It is always to be 
borne in mind that gangrene occurring in hysterical 
women is apt to be self-imposed. If such cases are care- 
fully noted, it will be observed that the spots appear 
where they can be most readily reached by the patient's 
right hand, or left, if she be left-handed. A case of that 
sort was recently seen by me, which rapidly became well 
as soon as I told the girl that she knew the cause of the 
trouble as well as I did, and need have no more of it un- 
less she wished. 



DERMATITIS GANGRENOSA. 157 

Treatment. In all these forms of gangrene attention 
must be given to the general health of the patient and the 
lesions must be treated on general antiseptic principles. 

There are two forms of cutaneous gangrene that have 
received special names that must be noticed here. They 
are : 1. Symmetrical gangrene or Raynaud's disease ; and, 
2. Dermatitis gangrenosa infantum. 

1. Symmetrical Gangrene. This was first described by 
Maurice Raynaud/ and since then has been observed by 
others, although it is a very rare disease. It most often 
attacks the second and third phalanges of the fingers and 
toes ; next most frequently the nose and ears, but any 
part may be attacked. The parts become pale and hard 
and then swell. They feel numb, but the patient may ex- 
perience darting or stabbing pains in them. If pricked, 
no blood escapes. The process may stop here and the 
parts may return to their normal state ; or, after a time, 
hours or weeks, they become black, a line of demarcation 
forms and separation of the affected skin takes place. 
The process may stop short of the complete destruction 
of the part and recovery may take place, though relapses 
are liable to occur. The disease is symmetrical. It may 
involve all four extremities, but usually only two are af- 
fected. Bullae may form. The nails may fall. 

Etiology. Men are more often affected than Avomen. 
People of all ages are liable to it. Exposure to cold 
seems to be a causative factor, and not a few of its vic- 
tims have been subject to chilblains or other symptoms 
of poor circulation. The malarial cachexia and the gouty 
habit have been supposed to be predisposing causes. It 
is probably of neurotic origin. 

Treatment. The internal treatment that has done 
best has been the administration of quinine and belladonna. 
Locally, galvanism may be tried, as it has done good. 
Cold applications are said to be better than hot. If 
gangrene has occurred, it must be treated on surgical 
principles. 

1 These de Paris, 1862. 






158 DISEASES OF THE SKIN. 

Prognosis. The outlook is not good. Death may re- 
sult in those who are not robust. Even if one attack is 
recovered from, another is apt to occur. 

2. Dermatitis Gangrcenosa Infantum (Crocker). Syno- 
nyms : Varicella gangrenosa (Hutchinson) ; Pemphigus 
gangramosus (Stokes) ; Pupia escharotica (Fagge) ; Ec- 
thyma infantile gangreneux (Pineau) ; Gangrenes multiples 
cachectiques de la peau ; Ecthyma terebrant de Fenfance 
(Baudouin). 

Under these names has been described a disease of the 
skin that occurs most often after varicella, but may occur 
after other diseases of the skin in children. It consists 
essentially in the formation of deep or superficial round or 
oval ulcerations beneath a black slough, and following 
upon a varicella or other pustule. The lesion when fully 
formed may be one inch or more in diameter, and three- 
quarters of an inch deep. The wider the slough, the 
deeper is the ulcer. Around the slough is a red areola. 
Crocker says that if the gangrene occurs while the varicella 
is still present, it begins on the head or upper part of the 
body, and then looks like a vaccination pustule ; while if 
it begins late in the course of the disease, the lesions will 
be located on the lower half of the body, especially the 
buttocks and thighs. In the latter case the affected parts 
are riddled with ulcers of all sizes, shapes, and depths. If 
several ulcers run together, very large and irregular ones 
may form. If the lesions are extensive or numerous, they 
may cause death very frequently by pulmonary complica- 
tions. 

Etiology. Infants and young children under three 
years of age are those affected by this disease, and most of 
them are girls. Debilitating diseases, such as congenital 
syphilis, tuberculosis, and scrofula so called, predispose 
to the disease. In my service at the Infants' Hospital 
on Randall's Island cases of this sort were not infrequent. 
In an epidemic of varicella, occurring in 1890, two cases 
were met with, one quite extensive upon the upper part 
of the back. The children received in the institution are 



DERMATITIS HERPETIFORMIS. 159 

from the lowest dregs of our population, and the disease 
seems to be a product of several dyscrasic conditions plus 
a possible microbic infection. 

Treatment. The cases are to be managed upon gen- 
eral principles. Tonics, fresh air, good food and hygienic 
surroundings, and remedies addressed as far as may be to 
the underlying constitutional condition are the best means 
for combating the disease. Crocker recommends quinine 
and sulpho-carbolate of soda, five grains every three 
hours. Locally, the Randall's Island cases were treated 
with iodoform and antiseptic dressings. Aristol would 
probably answer well. 

Prognosis. The prognosis is not good in bad cases. 
Death is apt to result from lung complications, or pysemic 
infection. 

Dermatitis Herpetiformis. This name was first sug- 
gested by Duhring, l of Philadelphia, for a disease which 
is characterized by great multiformity, and marked group- 
ing of the lesions ; by pruritus of varying intensity ; by 
chronicity of course ; and by a strong tendency to relapse. 
Under it he includes the hydroa of Bazin and Tilbury Fox, 
the herpes phlyctsenodes of Gibert, the herpes gestationis 
of Bulkley, pemphigus pruriginosus and circinatus, pem- 
phigus a petites bulle, hydroa bulleux, and the herpes cir- 
cinatus of Wilson. Though the name has been adopted 
generally, the exact status of the disease has not been set- 
tled. The account of the disease given here is based upon 
Duhring's writings. 

Symptoms. In severe cases there may be prodromata 
for several days preceding the outbreak, such as malaise, 
constipation, fever, chills, sensations of heat or cold, or 
these alternating, and itching. In mild cases these are 
absent. The onset of the disease may be gradual or 
sudden — the latter not infrequently. The eruption may 
be diffused over the greater part of the general surface, 
or it may be in localized patches. Itching and burning, 

Mourn. Amer. Med. Assoc. 3/ 1884, iii., 225. 



160 DISEASES OF THE SKIN. 

which are severe, precede or accompany the outbreak. 
It may begin as an erythematous, vesicular, bullous, pus- 
tular, or papular eruption, or by a combination of two or 
more of these, the multiformity being a characteristic. It 
shows a tendency for one variety of lesions to pass over 
into another, either during the attack or at some relapse. 
The relapses occur at intervals of weeks or months. All 
regions are invaded, the course is essentially chronic, and 
in pronounced old cases the skin is excoriated and pig- 
mented. The mucous membranes may be involved. 

Dermatitis herpetiformis erythematosa. This form is 
usually of urticarial or erythema-multiforme type and 
occurs either in patches or diffused. The circumscribed 
patches may coalesce and form larger patches with mar- 
ginate outline. The color varies with the age of the lesion, 
becoming darker with age. There may be maculo-papules, 
flat infiltrations, or vesico-papules, It may continue in 
this way for days or weeks, but usually it changes to the 
multiform type. There is pruritus. 

Dermatitis herpetiformis vesiculosa. This is the form 
most usually met with. The vesicles are from pinhead 
to pea-sized, flat or raised, irregular or stellate in shape, 
glistening, pale-yellow or pearly, firm, tensely distended 
and without areola. There may be papules, papulo-vesi- 
cles, vesico-pustules, and sometimes bulla?. The lesions 
are disseminated, but aggregated into clusters of two, 
three, or more, or may form groups as large as a silver 
dollar. If the vesicles are near together, they tend to 
run together and form blebs, which are raised and sur- 
rounded by a pale or distinct red areola, and of a puckered 
or drawn-up appearance. The eruption is usually profuse. 
All regions are affected. Severe itching and sometimes 
burning last until the vesicles are broken, which may not 
be for several days. Sometimes there is a good deal of 
constitutional disturbance. This is Fox's hydroa herpeti- 
forme. 

Dermatitis herpetiformis bullosa. In this form we have 
more or less typical bullae filled with cloudy or serous 



DERMATITIS HERPETIFORMIS. 



161 



fluid, from pea- to cherry-sized, irregular or angular in 
outline, and with or without an inflammatory base. They 
occur in groups, with red and puckered skin between, and 



Fig. 17. 




Hand of a person affected with dermatitis herpetiformis. (From a replica o 
retta's model, No. 1333, in the Museum of the St. Louis Hospital, Paris.) 



of Ba- 



more or less vesicles and pustules disseminated over the 
skin. All parts of the body are affected. They come 
out in crops at intervals, rupture in two or three days, 
and crust over. This is Fox's hydroa bulleux. 

11 



162 DISEASES OF THE SKIN. 

Dermatitis herpetiformis pustuloses This form is less 
clearly defined than the vesicular form, because vesicles, 
vesico-pustules, and bullae often occur at the same time. 
It may occur uncomplicated and be pustular throughout. 
The pustules are acuminated, round or flat, tense or flaccid, 
and vary in size from a pin-point to a twenty-five-cent 
piece. The large pustules generally have an areola. They 
tend to flatten, spread, and dry in the center, and to group. 
On the trunk we may find a central pustule surrounded 
by a variable number of small pustules. They are opaque, 
and whitish or yellowish. There may be slight hemor- 
rhagic exudation into them. They are slow of develop- 
ment, an attack lasting from two to four weeks. There 
is more marked constitutional disturbance than in the 
other forms. It is accompanied by heat, pricking, and 
itching. It sometimes precedes, follows, or alternates 
with the other forms. 

Dermatitis herpetiformis papulosa. This is the rarest 
and mildest variety of all, and consists in small or large, 
irregularly shaped, firm, reddish, or violaceous papules in 
disseminated groups, the papules being usually excoriated 
on account of the scratching to relieve the severe itching. 
Ill-defined papulo-vesicles are also present. 

Dermatitis herpetiformis multiforme is simply a combina- 
tion of all the former varieties, with the type changing 
from time to time. Pigmentation is a feature of this 
variety as well as in all the others, after the disease has 
lasted for some years. 

Etiology. The disease occurs in both sexes, and is 
supposed to be a tropho-neurosis. It occurs in all ages, 
but most commonly between thirty and sixty years of age. 
Little is known as to its causes. It occurs quite inde- 
pendently of pregnancy, and in one case became better 
during the same. Another case was aggravated during 
pregnancy, and by irregular menstruation. One case 
seemed to arise from a nervous shock. Most cases are 
seen in the subjects of nervous exhaustion of various 
kinds. By Bazin the gouty diathesis was considered to 



DERMATITIS HERPETIFORMIS. 163 

be a predisposing cause of hydroa, and hence possibly of 
dermatitis herpetiformis. Winfield has reported four cases 
in which sugar was found in the urine. Occasionally sep- 
ticaemia may stand in causal relation to the disease. 

Diagnosis. The disease must be differentiated from 
erythema multiforme, eczema, and pemphigus. It differs 
from erythema multiforme by not occurring markedly upon 
the backs of the hands, wrists, forearms, and feet ; by its 
more intense itching, instead of the burning of erythema ; 
by its chronicity and greater tendency to relapse ; and by 
its obstinacy to treatment. If the case is watched for a 
time, the character of the eruption will be seen to change. 

The vesicular form of dermatitis herpetiformis differs 
from vesicular eczema in having larger vesicles of angular 
or stellate outline, and with no disposition to rupture ; in 
the grouping of these vesicles in small clusters ; in its her- 
petic character ; more intense itching ; greater constitu- 
tional disturbance ; and greater obstinacy to treatment. 

The papular form differs from papular eczema in the 
irregularity of the size and form of the papules ; their 
strong disposition to group ; their slow evolution ; their 
appearance in crops with free intervals ; the chronicity of 
its course ; and obstinacy to treatment. 

It differs from herpes iris by being a general eruption, 
and by not having the groups of vesicles arranged in cir- 
cles about a central vesicle. 

It differs from pemphigus by the grouping of its lesions, 
by their more inflammatory, herpetic aspect, and by the 
occurrence of vesicles and pustules at the same time with 
the bullae. If only bullae are present, the diagnosis is 
difficult. 

Impetigo herpetiformis is always and only pustular, and 
never has erythematous patches, vesicles, or bullae. It 
develops by new lesions springing up in a circular manner 
about the old ones. It is unattended by pruritus, and is 
a grave disease, often ending fatally. 

A well-marked case of dermatitis herpetiformis with 
erythematous patches, grouped vesicles, pustules, and 



164 DISEASES OF THE SKIN. 

bullae of stellate form, intensely pruritic and with a 
myriad of excoriations, is so characteristic as to admit of 
no doubt in diagnosis. 

Pathology. A careful study of herpetiform hydroa 
has been made by G. T. Elliot. 1 This is considered by 
Duliring as one variety of the disease under consideration. 
He shows that the vesicles originate in the epithelium of 
the sweat ducts, several being implicated at the same time, 
and that the ordinary signs of inflammation are present. 
He believes that the inflammation is secondary, and is 
seated in the papillary layer of the corium. Degenerated 
nerve fibers are found, and the disease is believed to be 
due to trophic nerve disturbance. Laredde and Perrin 2 
are of the opinion that eosinophile cells are closely related 
to the process of bullous formation, and that there is a 
vasomotor paralysis allowing of the escape of bloody or 
lymphatic serum in the connective tissue and the formation 
of bullae . They raise the question of a possible relation 
between renal action and the escape of eosinophile cells. 
T. C. Gilchrist's 3 studies show that in the early stages 
the vesicles are formed beneath the epidermis on account 
of an inflammatory process going on in the corium. He 
also notes the presence of the eosinophile cells. 

Treatment. This disease is one of the most rebellious 
to treatment. Hygienic measures, fresh air, proper and re- 
stricted diet, abstinence from all alcoholics, and relief from 
all nervous disturbances must be secured as far as may be. 
Nerve tonics may be given, such as arsenic, strychnine, 
cod-liver oil, hypophosphites, and quinine ; alkaline di- 
uretics, belladonna in full doses, laxatives, all may be 
tried. Phenacetine, 5 to 10 grains, three times a day 
has done well in some cases. Antipyrine exerts a more 
powerful influence but is not so safe. Locally Duhring 
has found the best treatment to be sulphur ointment con- 
taining two drachms of sulphur to the ounce, well rubbed 

iN. Y. Med. Jour., 1887, xlv., 449. 
2 Annal. de derm, et syph., 1895, vi., 281. 
3 Johns Hopkins Hosp. Eep., Vol. I, 



DERMATITIS MEDICAMENTOSA. 165 

in with vigorous friction as in scabies. In one marked 
case this treatment gave most satisfactory results in my 
hands. The frictions should be continued for an hour at 
a time. This plan is not suitable for the erythematous 
variety. Other authorities recommend alkaline and bran 
baths, dusting on starch powder with zinc, Lassar's paste, 
resorcin ointment, liquor carbonis detergens in water, 
5ij to Sviij ; calamine lotion, liquor picis alkalinus, tar 
ointment, solutions of carbolic acid, 3j to 3j, dabbed on. 
All these will afford a certain measure of relief, but the 
disease is apt to laugh at our efforts to drive it away. 

Prognosis. The duration of the disease is indefinite. 
Some mild cases may recover in a short time, never to re- 
lapse. The course of the disease is essentially chronic ; it 
may last for many years ; it shows a strong tendency to 
relapse at longer or shorter intervals ; and, as a rule, does 
not materially affect the patient's health. 

Dermatitis, Malignant Papillary. See Paget' s Disease 
of the Nipple. 

Dermatitis Medicamentosa. By this is meant inflam- 
mation of the skin due to the systemic ingestion of drugs. 
There are a great number of drugs that may cause erup- 
tions upon the skin in susceptible individuals. These ef- 
fects are seen but rarely with some drugs, and quite con- 
stantly with others. The modus operandi of drugs in 
producing eruptions is probably not the same in all cases. 
Some, doubtless, act by irritating the skin while circulat- 
ing in the blood ; some while being excreted by the glan- 
dular apparatus ; while most of them do so by direct or 
reflex excitation of the vasomotor nerves. Idiosyncrasy 
is marked in all of them. Erythema is the principal fea- 
ture of nearly all drug eruptions, to which may be added 
vesiculation or pustulation. Two drugs, bromine and 
iodine, produce pustular eruptions in nearly all cases 
where ingested. Most drug eruptions appear with more 
or less suddenness, and disappear quite promptly when 
the drug is stopped. They are symmetrical and general 



166 DISEASES OF THE SKIN. 

in distribution as a rule. They may be universal or local- 
ized. The cause of all doubtful eruptions of an erythema- 
tous type should always be sought for in the ingestion of 
some drug. As a rule, little if any treatment is required 
for this form of dermatitis apart from stopping the drug. 
Sometimes the system becomes accustomed to a drug, and 
after a time does not react unfavorably to it if its admin- 
istration is persisted in. With most drugs this is not the 
case. 

The subject of drug eruptions is so large a one that here 
no more than a skeleton account can be given. For fuller 
particulars the reader is referred to Morrow's masterly 
article in his System of Genito- Urinary Diseases, Sy philol- 
ogy, and Dermatology, Volume III., upon which this sec- 
tion is founded. 

Acids : Benzoic acid may produce an eruption of urti- 
caria, maculo-papules, or erythema. Boric acid may cause 
an erythematous, psoriatic, or erythema to-bullous eruption. 
The psoriatic form is unique. Carbolic acid causes an ery- 
thema that may be scarlatinous in character. Nitric acid, 
in rare cases, gives rise to a pustular eruption. Salicylic 
acid and salicylate of soda produce erythematous, urti- 
carial, vesicular, bullous, petechial, or purpuric manifesta- 
tions. Salol has produced urticaria. Tannic acid caused 
an erythema in one case. 

Aconite gives rise to itching, vesicular, pustular, or 
bullous lesions. 

Alcohol may cause a generalized erythema and urti- 
caria. 

Amygdala amara causes erythema. 

Antifebrin may give rise to cyanosis. 

Antimony causes an urticarial or vesiculo-pustular erup- 
tion. 

Antipyrin gives rise to an erythema, consisting of small, 
insularly circular, slightly elevated patches, which may 
be discrete or confluent, and is at times followed by des- 
quamation. Profuse sweating and itching may accom- 
pany it, and it affects the chest, abdomen, back, and ex- 






DERMATITIS MEDICAMENTOSA. 167 

tremities, specially their extensor surfaces. It may be 
measly in character or purpuric. It has also given rise 
to bullous, furuncular, and purpuric eruptions. 

Argentum nitras when used continuously may produce a 
grayish-black discoloration of the skin, or an erythemato- 
papnlar eruption. 

Arsenic causes erythema of scarlatina type, papules, 
petechia?, urticaria, vesicles, pustules, herpes zoster, and 
an erysipelatous eruption. Itching may attend some of 
these eruptions. Grayish or brownish discolo rations of 
the skin have followed prolonged ingestion of the drug. 
Boils and carbuncles have also been produced, as well as 
thickening of the skin of the palms and soles, and that 
over the knuckles, either in the form of diffused kera- 
tosis or as numerous small corns. 

Belladonna produces a scarlatinal eruption with or 
without vesicles and pruritus. As the fauces are often 
reddened the resemblance to scarlatina is striking. It 
will clear up in twenty-four hours, and the eruption is 
patchy, not punctate. Moreover, there is none of the 
prodroma of scarlatina, nor the strawberry tongue. The 
pupils may be dilated. 

Bromine, in combination with potassium, ammonium, 
and other salts, produces the well-known " bromic acne " 
so commonly seen in the treatment of epilepsy. It is an 
outbreak of dark-red inflammatory papules, papulo- 
pustules, and cutaneous abscesses that bear a close resem- 
blance to acne, and, like it, often leave scars. It differs 
from acne in having a wider distribution, and in occurring 
at all ages. This is the most common form of bromine 
eruption, but erythematous, urticarial, papular, ulcerative, 
verrucose, vesicular, and bullous eruptions have been met 
with. Rarer forms are papillary hypertrophy, resembling 
condylomata, and large, irregular, elevated ulcers. It 
would be desirable to prevent these eruptions, but thus far 
there is nothing that will do so with certainty, except stop- 
ping the administration of the drug. Arsenic, or sulphide 
of calcium, or aromatic spirits of ammonia may be tried. 



168 



DISEASES OF THE SKIN. 



Calx sulphurata gives rise to vesicles, pustules, and 
furuncles ; rarely to petechia?. 

Cannabis indica caused a vesicular eruption in one case. 

Cantliarides gives rise to erythematous and papular 
lesions. 

Capsicum may cause erythematous and papulo-vesicular 
lesions. 




Bromide of potassium eruption in a child. 



Chloral produces erythematous, papular, urticarial, ve- 
sicular, and petechial eruptions. At times the chloral 
erythema bears a strong resemblance to scarlatina. 

Chloralamide causes a general punctate hyperemia with 
vesicular lesions with febrile reaction. 

Cinchona and quinine produce all the primary lesions 
of the skin, though most frequently an erythema of scar- 
latina type, attended by congestion of the fauces and 
followed by desquamation. 

Conium has an erysipelatous eruption as well as an 
erythematous one. 



DERMATITIS MEDICAMENTOSA. 169 

Copaiba and cubebs. Their most common eruption is 
an erythema which is often of a scarlatina type, but may 
resemble measles, and may be followed by desquamation. 
Outbreaks of urticaria, vesicles, bulla?, or petechia? may 
occur. Pruritus may be present. The odor of the drug 
may usually be detected in the breath. 

Digitalis produces an erythema of an erysipelatous, 
papular, or urticarial character. 

Ergot, quite apart from the condition of ergotism, may 
cause vesicles, pustules, furuncles, and petechia?. 

Guaiacum and gurjun oil cause eruptions like those of 
copaiba. 

Hydrargyrum gives rise to a scarlatiniform eruption, 
followed by desquamation, as well as urticaria, herpes, 
impetigo, purpura, furuncles, and ulcers. 

Hyoscyamus produces an itching erythematous erup- 
tion, with more or less oedema and wheals. Purpura has 
also followed its use. 

Iodine and its compounds, like bromine, give rise to 
a pustular or papulo-pustular, acneiform eruption, usu- 
ally upon the face, back, and upper part of the chest and 
arms ; but often general. This is the most typical form 
of eruption, but an erythema limited to the face and chest 
or general, an urticaria, a vesicular erythema, or an ec- 
zema-like eruption, a bullous form resembling pemphigus, 
as well as carbuncular, petechial, and nodular eruptions, 
may occur. Sometimes there will be more than one type 
present. It is supposed that iodic eruptions occur more 
often in cases in which the kidneys are more or less in- 
active. They sometimes follow the administration of 
very small doses. It is thought that the iodide of so- 
dium is less apt to cause cutaneous disturbances than are 
the other salts of iodine. At times the system becomes 
accustomed to the drug, or the kidneys acting more freely 
relieve the skin. The trouble may be relieved or, to a 
large extent, obviated by administering the salt largely 
diluted in vichy or seltzer water, or giving it in milk. 
The free use of alkaline diuretics will relieve the skin. 



170 DISEASES OF THE SKIN. 

Arsenic has also been commended, but does no better here 
than in the bromine eruptions. 

Ipecac in one case caused burning heat, with an ery- 
sipelatous eruption. 

Iron is said to produce an acne ; also erythematous, 
vesicular, and urticarial eruptions. The iodide of iron is 
the form that usually produces these eruptions. 

Morphine may cause urticaria, ulcers, a papular, vesic- 
ular, or pustular eruption. 

ISTux vomica and strychnine have given rise to a scarla- 
tina-like erythema and a miliary eruption. 

Oleum morrhuse may cause an eczematous eruption or 
an acne. Oleum ricini may cause an itching erythema. 
Oleum santali may cause a general petechial eruption. 

Opium causes itching and an erythema resembling scar- 
latina or measles in character, which, though often widely 
distributed, is not infrequently limited to certain regions. 

Phenacetin may cause a general erythematous eruption. 

Phosphorus causes bullous eruptions, and also purpura. 

Pix licjuida produces an erythema. 

Potassium chloras has caused a papular erythema, while 
bluish spots on the skin and a general cyanosis may occur 
after continuous use of the drug. 

Quinine produces a scarlatiniform erythema, as well as 
urticarial, purpuric, vesicular, and bullous eruptions. 

Rhubarb may cause a scarlatiniform erythema. 

Santoninum produces an urticaria or a vesicular erup- 
tion. 

Stramonium gives rise to an itching or burning scarlati- 
noid erythema, a petechial eruption, or an erysipelatoid 
inflammation. 

Strichnine may cause a scarlatiniform rash. 

Sulphonal produces a scarlatiniform erythema. 

Sulphur causes dark discoloration of the skin, and an 
eczematous, pustular, furuncular, or papular exanthem. 

Tuberculin may cause scarlatiniform or measles-like 
patches of erythema, as well as a psoriasiform eruption. 

Tansy has caused a varioliform eruption. 



DERMATITIS PAPILLARIS CAPILLITIL 



171 



Turpentine and terebene may cause scarlatiniform ery- 
thema and a papular and vesicular eruption. 

Veratria gives rise to an erythematous eruption. 

Treatment. The treatment of all drug eruptions is 
the same, namely, stopping the use of the drug and giving 
alkaline diuretics. Locally soothing remedies should be 
applied, such as cold cream, vaseline, and oxide of zinc 
ointment, or preferably alkaline lotions. 

Dermatitis Papillaris Capillitii. Synonyms : Dermati- 
tis papillomatosa capillitii ; Framboesia ; Sycosis framboe- 



Fig. 19. 




Dermatitis capillitii. 

sia (Hebra) ; Sycosis capillitii (Raver) ; Mycosis framboe- 
siodes, or Acne keloidique, or Pian ruboide (Alibert) ; 
Acne keloid. 

Symptoms. This is one of the rare diseases of the 
skin. It begins as an eruption of small-sized papules 
upon the back of the neck at the margin of the hair. 
They are of the color of the skin, or slightly red with an 
inflammatory halo ; exceedingly hard and firm ; and when 
pricked they give vent to a little bloody serous fluid. 
Increasing slowly in number and crowding together, they 
form raspberry-like elevations with uneven lobulated sur- 
faces. Gradually the disease spreads laterally and also 



172 DISEASES OF THE SKIN. 

upward upon the hairy scalp, even reaching the vertex 
after months and years. After a time the masses may 
soften a little and contain pus. At times they secrete a 
foul-smelling fluid, and crust. Gradually they become 
sclerosed and keloidal. Pustules may form on the hairy 
scalp, and little tufts of hair protrude out of them. When 
they become keloidal they may be bald or tufted with hair. 
Hairs plucked from the growths are sometimes normal, 
and sometimes atrophied. There may be pain or tender- 
ness, or there may be no subjective symptoms. 

Etiology. Both men and women are affected, and the 
disease may begin at any age. Negroes seem more subject 
to it than does the white race. The etiology is obscure. 
It has been suggested that it may be due to the rubbing 
of the shirt collar. 

Diagnosis. If the characteristics of the disease are 
remembered, there should be no difficulty in diagnosis. 
In sycosis we have no hard tumors, and the single hairs 
are surrounded by pustules. Warts are not so hard, do 
not tend to increase in size, and do not become keloidal. 

Teeatment. The best treatment is to scrape away the 
small lesions with the curette and excise the larger ones. 
After either operation the base must be cauterized. They 
may be removed with the galvano-cautery. 

Prognosis. So far as reported the growths are benign, 
and have no effect upon the health of the patient. They 
are progressive and show no tendency to spontaneous re- 
covery. They are obstinate to treatment and prone to 
relapse. 

Dermatitis Repens. Crocker describes this as a spread- 
ing dermatitis, usually following injuries, and probably 
neuritic, commencing almost exclusively on the upper ex- 
tremities. It begins about some slight injury, as about 
the finger nails, and spreads over the affected limb with a 
well-defined, undermined advancing edge. The eruption 
suggests eczema rubrum, but its sharply defined, under- 
mined spreading edge distinguishes it. It runs a chronic 
course and is obstinate to treatment. It yields best to 



DERMATITIS TRAUMATICA. 173 

antiseptics such as lactate of lead, hyposulphite of soda, 
permanganate of potash, and salicylic acid. 

Dermatitis from Roentgen Rays. In some 1,300 ex- 
posures to the X-rays the statistics of N. S. Scott 1 show 
that there will be one case of dermatitis. The dermatitis 
does not appear until some days or weeks after the ex- 
posure. The patient first notices an erythematous patch 
corresponding to the point of impact of the rays, attended 
by swelling of the skin. This is the mildest form and 
may soon disappear. In most cases the part is painful and 
the redness increases in area and assumes a purple hue. 
The pain when present is deep-seated and aching. Vesicles 
and sometimes bullae form, and later the central part of the 
patch becomes raw, moist, and tends to remain for months 
without healing. The hair and nails may be shed, but 
they are not permanently lost, as a rule. It is not deter- 
mined what the cause of the dermatitis is, whether the 
generation of ozone, or of heat, or of bombardment of the 
skin with infinitesimal particles of metal. The placing 
of a screen of aluminum gauze between the patient and 
the tube is recommended as a preventative of injury. As 
the cases arise on account of too long exposure with a 
tube placed too near the subject, short sittings and the 
greatest possible working distance would seem to be the 
most rational prophylaxis. 

The treatment is most unsatisfactory and is along sur- 
gical lines. In some cases the patch has been excised in 
the hope of obtaining a healthy surface. 

Dermatitis Traumatica. This term is used to comprise 
all inflammations of the skin that are due to traumatic in- 
fluences, such as blows, rubbing and the like. It presents 
the usual signs of inflammation to a greater or less extent, 
according to the degree of traumatism and the suscepti- 
bility of the individual skin. The irritation of the skin, 
due to scratching, is a common instance of this form of 
dermatitis. Under certain circumstances it easily de- 

1 Amer. X-Rav Jour., 1897, 1-57. 



174 DISEASES OF THE SKIN. 

velops into an eczema. The chafing of the skin met with 
in horseback-riding, in those unaccustomed to the exercise, 
is another common instance. 

Treatment. The treatment of this form of dermatitis 
should be soothing, such as by the free use of dusting 
powders, alkaline lotions, or mild ointments, such as that 
of the oxide of zinc. Unna 1 recommends for the pre- 
vention of the dermatitis due to horseback-riding, that 
the part should be smeared over with a weak resorcin or 
ichthyol ointment. 

Dermatitis Venenata. Redness, swelling, and heat, fol- 
lowed or attended by the formation of a vast number of 
small, closely crowded together vesicles that may remain 
isolated or run together and form bullae, are the symptoms 
that constitute this form of dermatitis, the cause of which 
is always some sort of irritant applied to the skin. The 
irritant is usually of a chemical nature, and quite com- 
monly is derived from plants. 

Bhus-poisoning. The most frequent cause of dermatitis 
venenata is contact of the susceptible skin with the leaves 
of the rhns toxicodendron, the poison-ivy, and the rhus 
venenata, the poison-sumach, and the rhus cliversiloba, the 
poison-oak. Dr. James C. White, 2 of Boston, has writ- 
ten a most complete and learned work on the subject, 
and it is to this that the reader is referred for a more de- 
tailed account of the disease than can be here given. 
The mildest degree of irritation is an erythema. Com- 
monly the reaction is more marked. The patient first 
experiences a little burning or itching, and attention be- 
ing drawn to the part it is found to be reddened and 
swollen. In some cases we may have wheals. In a few 
hours papules, and then vesicles, will form and perhaps 
bullae. The swelling may be intense, so as, on the face, 
completely to close the eyes. I have seen it so great on 
the scrotum as to give the appearance of an immense 
hydrocele. The vesicles may be present in a countless 

1 Monatshefte f. prakt. Dermat., 1888, No. 21. 

2 Dermatitis Venenata. Boston, 1887. 



DERMATITIS VENENATA. 



175 



multitude. The acute developing symptoms may last 
several days, and then gradually subside. The vesicle 
contents either dry up or discharge upon the skin. The 
parts crust, the swelling and redness slowly disappear, and 
the skin once more becomes normal. When the dermatitis 

Fig. 20. 




Dermatitis venenata from poison-ivy. 1 

is due to the poison-ivy the cause of the trouble is sup- 
posed to be toxicodendric acid. The parts most usually 
affected are the hands and face in both sexes, the penis in 
the male and the breast in the female ; that is, those parts 
that come in direct contact with the poison, or to which it 
is most liable to be conveyed by the hands. In some rare 
1 From a photograph by Dr. H. W. /Blanc, of New Orleans. 



176 DISEASES OF THE SKIN. 

cases, and in extremely sensitive individuals, the whole 
body may be affected, and there may be grave constitu- 
tional disturbances. These bad cases are met with in 
children whose legs are uncovered. Most persons, per- 
haps, are not susceptible to the poison. Some few are so 
susceptible that even having the wind blow on them from 
over one of the plants will set up the dermatitis. 

It is probably not true that the dermatitis will relapse 
after an interval of time, but it has been observed that an 
eczema may follow the dermatitis, and that this may show 
a certain amount of periodicity in its outbreaks. White 
says that while the poison may be most active in the 
flowering season, it is sufficiently active at all seasons, and 
that the poison resides not only in the leaves but also in 
the wood, bark, and fruit. The disease is not contagious 
after the parts have been well washed. 

Diagnosis. The eruption differs from that of eczema 
by seeking the inner sides of the fingers, the hands, face, 
breasts, and genitals ; by the greater amount of swelling 
that commonly attends it ; by the vast number of crowded 
together, "lurid" vesicles; and by the occasional occur- 
rence of the eruption in its early stage in streaks, sugges- 
tive of striking against the plant. A history of having 
been in the country will sometimes be an aid in diagnosis. 

Treatment. The disease is a self-limited one. It is, 
therefore, natural that there are many " sure cures " for it, 
and nearly every section of the country has some popular 
remedy. Lime-water, that can be procured anywhere, will 
afford relief as promptly as anything. The parts are to be 
kept constantly covered with lint or absorbent cotton con- 
tinuously saturated with it, or with a saturated solution of 
bicarbonate of soda. At night we cannot use this if the 
patient sleeps, as the cotton or the lint dries. So it is better 
at this time to use some simple ointment, as cold cream, 
oxide of zinc, or diachylon diluted one-half. This treat- 
ment commends itself on account of its efficacy, cheapness, 
safety, and accessibility. Ichthyol in aqueous solution 
from 10 to 40 per cent, strength is highly commended by 



DERMATITIS VENENATA. 177 

some. White recommends black wash (calomel, oj ; aq. 
calcis, Oj), applied for half an hour at a time, two or three 
times a day. He cautions against the danger of using it 
in extensive cases. As a substitute for it he gives : 

R. Zincioxid., ^ir; 16 

Ac. carbol., 5J5 4 

Aq. calcis, Oj; 500 M. 

Sugar of lead in solution is a well-known remedy, and 
efficacious, but dangerous. Morrow l recommends : 

R. Sodii hyposulphitis, 5JI 251 

Glvcerini, 3 s8 ; 12 

Aquae, ad gviij; 200 M. 

S. Keep constantly applied. 

After the acute stage has passed the case should be 
treated like an eczema. If the constitutional disturbance 
is marked, the patient should be cared for upon general 
medical principles. 

While the poison-oak, or ivy, causes the symptoms most 
often spoken of as dermatitis venenata, there are a num- 
ber of other plants that will produce like, if not as severe, 
symptoms. Of the commoner ones we find the oleander, 
Jack-in-pulpit, skunk cabbage, bitter orange, May-apple, 
arnica, burdock, golden rod, and common daisy. But 
space will not allow of a complete list of these. Goa 
powder and its derivative, chrysarobin, produce a marked 
dermatitis in addition to their mahogany-staining of the 
skin. The action of croton oil, mustard, stinging-nettle, 
and oil of turpentine is well known. Tar may excite a 
general dermatitis or an acne-like inflammation of the 
follicles called " tar acne," the follicles of the skin being 
stopped up and their mouths filled with a black plug of 
tar. A somewhat similar eruption is seen in workers in 
flax and paraffin. Workers in picking and packing peaches 
have an eczematous dermatitis developed upon the wrists, 
forearm, neck, and upper part of the chest. 

1 Journ. Cutan. and Yen. Dis.,iv., p. 180, 1886. 
12 



178 DISEASES OF THE SKIN. 

A great number of chemicals produce dermatitis of 
varying degree. Pyrogallic acid produces burning and 
inflammation, and covers the part with a black coating on 
account of its oxidation. Not only does it destroy dis- 
eased tissues, but it may cause sloughing of the sound 
skin. Chloroform will blister if prevented from evapora- 
tion. This peculiarity is sometimes employed for vesica- 
tion. The strong acids destroy the skin, as also arsenic. 
Sulphur, iodine, iodoform, creolin, mercurial preparations, 
chloride of zinc, bichromate of potash, and caustic potash 
cause varying degrees of dermatitis. Electricity will 
redden and inflame the skin, and not a few cases of der- 
matitis have resulted from wearing clothing dyed with 
aniline dyes. 

Dermatolysis (Du 5 rm-a 2 t-o 2 l / i 2 -si 2 s). Synonyms : Cha- 
lastodermia ; Cutis pendula ; Pachydermatocele. 

This term is applied to two entirely different diseases 
of the skin. In one we have folds of loose thickened 
skin and subcutaneous tissue that sometimes form huge 
masses hanging down from the side of the face, trunk, or 
any part of the body. The skin is soft, and does not ap- 
pear altered, excepting that it is pigmented to a certain 
extent. This form is really a species of fibroma. True 
dermatolysis is a yet more rare affection, in which, owing 
to some defect in the attachments of the skin, it can be 
pulled away from the body like the skin of a cat. The 
" Elastic-skin Man " is an instance of this. There have 
been several of these freaks. The one mentioned could 
pull the skin from his chest up to his eyes. The condi- 
tion is congenital, but can be increased by cultivation. 

Treatment. The treatment of the first variety is by 
excision before it becomes too large. 

Dermatomycosis. A disease of the skin due to a vege- 
table parasite. 

Dermatosclerosis. See Scleroderma. 

Dermatosis Kaposi. See Atrophoderma pigmentosum. 



ECCHYMOMA TA. 179 

Dermatosis Linearis Neuropathica. See Xaevus unius 
lateris. 

Dermographia. See Urticaria factitia. 

Desmoides. See Fibroma. 

Diabetic Eruptions. According to Broeq, they may be 
divided into two great classes : 1. Those in direct rela- 
tion to alterations in the general economy, such as 
pruritus, chronic papular urticaria, acne cachecticornm, 
erythema, lichen, eczema, herpes, ecthyma, furuncle, car- 
buncle, xanthelasma, gangrene. 2. Dermatoses due di- 
rectly to the contact of the secretions of the body charged 
with sugar, and more especially the eczema of the gen- 
itals, caused by contact with the urine. 

Kaposi l has described a bullo-serpiginous gangrene of 
diabetics which begins as a disseminated eruption of bul- 
lae upon the extremities. The bulla? dry up in the center 
into a black crust, while at the periphery there is a ring 
of fluid pushing up the epidermis. When the crust is 
removed sphacelated skin is exposed, which separates and 
leaves a red, granulating surface. The penis is a favorite 
site for this form of gangrene. It must be treated on 
general surgical principles. 

Distiehiasis (Drs-trk-i-a'srs). This is a congenital or 
acquired condition of the cilia, in which they grow in two 
distinct rows, the inner row being directed inward so as 
to scrape the cornea. According to Michel, generally the 
outer third of the upper lid is affected alone, the defor- 
mity is symmetrical and bilateral, and of embryonic ori- 
gin. Electrolysis offers the best method of relief. These 
cases belong to the ophthalmic surgeon. 

Dracontiasis. See Guinea-worm disease. 

Durillon. See Callositas. 

Dysidrosis. See Pompholyx. 

Dystrophic papillaire et pigmentaire. See Acanthosis 

1 AVien. med. Presse, 1883. 



180 DISEASES OF THE SKIN. 

Ecchymomata and Ecchymoses. See Purpura. 

Ecdermoptosis (Huguier). See Molluscum epitheliale. 

Ecphyma Globulus is described by H. L. Purdon l as a 
contagious disease occurring in Ireland. It begins as a 
tubercle which, after a time, softens and is replaced by a 
raspberry-like tumor. All parts of the body may be af- 
fected excepting the hands and feet. It is chronic in its 
course, but can be cured by applications of the nitrate of 
silver. 

Ecthyma (E 2 k-thi'ma 3 ). Synonyms : Furunculi aton- 
ici ; Phlyzacia agria ; (Ger.) Eiterpusteln ; (Fr.) Furoncles 
atoniques ; (Ital.) Rogna grossa. 

A cutaneous eruption of deep-seated pustules, with hard, 
elevated, reddened bases, attended by the formation of 
thick, greenish, or dark-colored crusts, and followed 
either by cicatrices or dark pigmented spots. 

Symptoms. Most if not all cases of so-called ecthyma 
are either pustular eczema, or more probably a contagious 
disease allied to if not identical with impetigo contagiosa. 
As usually described it consists in the outbreak of one or 
more round, flat pustules, whose covers are not fully dis- 
tended, and which have an inflammatory areola. In size 
they vary from a split pea to a finger nail, or larger. At 
first they are white or yellow. Subsequently they may 
or may not become reddish from the admixture of blood. 
They may dry up, forming a crust which, on falling, 
leaves a healthy surface. Or they may rupture spon- 
taneously or be broken, and form a thick, greenish or 
blackish crust, under which is a raw or superficially 
ulcerated surface, which on healing leaves a pigmented or 
slightly cicatricial spot. In subjects in bad hygienic sur- 
roundings quite deep ulcers may result. These pustules 
are usually discrete, but they may group. They are both 
painful and tender. Any part of the body may be affected, 
but they are most often seen on the extremities, especially 
the legs, where the hair is coarse, the shoulders and the 

Dublin Jour. Med. Sci., 1897, ciii., 486. 



ECTHYMA. 181 

back. The course of the disease may be acute, each 
pustule lasting five or ten days, and the whole disease 
lasting about two weeks, but generally it is chronic, and 
kept up by the outbreak of fresh crops. There is more 
or less itching, soreness, and pain. It is both contagious, 
and auto-inoculable. Febrile symptoms may accompany 
or precede the outbreak of the disease, but as a rule they 
are absent. 

Etiology. Dirt, want, bad hygienic surroundings, the 
strumous diathesis, or a broken-down cachectic condition 
brought on by intemperance or dissipation, all predispose 
to the disease. It is quite often seen in the genus " tramp." 
It follows, not infrequently, upon scratching on account of 
pediculi and scabies. It is most often seen in adults, 
and is rare in children. Like in all other purulent dis- 
eases, pus cocci are found in the pus, and are the con- 
tagious element in the disease which is carried from place 
to place to produce new foci of infection. 

Diagnosis. Ecthyma differs from eczema in having 
much larger pustules, which are discrete and not conflu- 
ent, in the marked areola about the pustules, and in the 
absence of all other signs of eczema. It differs from im- 
petigo contagiosa in its pustules being deeper ; in their lo- 
cation upon the extremities rather than upon the face and 
hands ; in not having that flabby, bullous look of a burn 
of the second degree, so common to impetigo ; in having 
thick greenish or blackish crusts, and not straw-colored 
stuck-on crusts ; in occurring in more or less debilitated 
adults and not in otherwise healthy children. But all 
these alleged differences can be readily explained away 
by the difference of the character of the soil on which 
the contagious principle is implanted. Ecthymatous pus- 
tules are often seen in connection with impetigo conta- 
giosa. From impetigo it differs principally in its being a 
deeper and more inflammatory process, and in occurring 
in debilitated subjects. It resembles the large, flat, pus- 
tular syphiloderm, but its crusts are not heaped up into 
oyster-shell-like masses, as in syphilis, and when they 



182 DISEASES OF THE SKIN. 

are removed they leave a more superficial, and not so 
punched ont an nicer. There are more pain and itching 
in ecthyma, and an entire absence of other symptoms or 
history of syphilis. 

Treatment. The first thing to be done in these cases 
is to obtain cleanliness, proper hygienic surroundings, and 
complete abstinence from alcoholics. If there is a general 
debility, tonics must be given and the dietary improved. 
Locally, all crusts must be removed with soap and water, 
the lesions dressed with an ointment containing some an- 
tiseptic such as — 

R . Hydrarg. ammon., Qj ; 51 

Ungt. zinci oxidi, 3j ; 100| M. 

and the parts enveloped in a rubber bandage, where such 
is applicable. An ointment or oil containing five or ten 
grains of salicylic acid to the ounce will also answer well. 
If ulcerations have formed, they should be treated as will 
be indicated under Ulcers. 

Ecthyma infantile gangreneux. See Dermatitis gan- 
grenosa infantum. 

Ecthyma terebrant de l'enfance. See Dermatitis gan- 
grenosa infantum. 

Eczema (E 2 k r -ze 2 m-a 3 ). Synonyms : (Fr.) Dartre vive, 
on humide, eczema ; (Ger.) Ekzem, Hitzblatterchen, 
Flechte, nassende Flechte, Salzfluss ; Salt rheum, Tet- 
ter, Humid tetter, Scall, Scald, Heat eruption. 

A non-contagious, inflammatory disease of the skin, 
sometimes acute, more often chronic, attended with itch- 
ing, desquamation or loss of the cuticle, and usually with 
the exudation of serous or sero-purulent fluid either be- 
neath the cuticle or upon the denuded surfaces. It may 
present erythema, papules, vesicles, or pustules, and its 
lesions show a decided disposition to run together and 
form infiltrated patches. 

Symptoms. This is a most protean disease. It has 
been well said that if a student learns to recognize and 



ECZEMA. 183 

treat syphilis and eczema, he has possession of the key to 
the whole of dermatology. There are six prominent 
symptoms of the disease : 

1. Redness. 

2. Itching. 

3. Infiltration. 

4. Tendency to moisture. 

5. Crusting or scaling. 

6. Cracking of the skin. 

In every case there will be four or live of these symp- 
toms ; or perhaps all of them. 

Eczema begins suddenly, and most often without any 
constitutional disturbance. Should slight fever and ma- 
laise be present they are accidental, or an expression of 
that condition of the system that predisposes to the dis- 
ease, and not part of the disease itself. Very often the 
first tiling that attracts the patient's attention is itching, 
and when he examines the skin he finds it reddened, and 
either scaly ; or covered with papules, vesicles or pus- 
tules ; or moist. 

The tendency of eczema in all forms is to form patches, 
which are infiltrated to a greater or less extent ; ill-de- 
fined ; shade off imperceptibly into the surrounding skin 
so that it is hard to say where they end, with outlying 
lesions about them ; irregular in shape ; of all sizes, 
sometimes involving nearly the whole cutaneous surface ; 
sometimes swollen, and of dark-red color ; sometimes 
with a shade of yellow. Beginning by a few lesions the 
disease increases more or less rapidly in extent, and it is 
by the running together of the individual lesions that the 
patches are formed. It may clear away after a short 
time, or it may last weeks or. months, or become chronic, 
showing little tendency to recovery. There is no con- 
stant rule as to the course of the disease, though many 
cases occur and recur at certain seasons of the year ; it 
may be in the summer, spring, autumn, or winter. Any 
or all parts of the skin may be affected, but it has a pre- 
dilection for the flexures of the joints, the face, the scalp, 



184 DISEASES OF THE SKIN. 

and the sulcus behind the ear. There may be but a 
single patch or many patches. It commonly affects both 
sides of the body, but with no marked symmetry. 

The subjective symptoms are itching, burning, and a 
feeling of heat and tension. Of these the most constant is 
itching, which is present in all cases, and is often so great 
as to cause the patient to excoriate the skin by scratching. 
It is subject to exacerbations and remissions. The latter 
may be complete or incomplete. Burning and tension are 
experienced for the most part only at the beginning of the 
attack or during some exacerbation of a subacute or chronic 
case. 

The old definition of the disease was that it is a vesicu- 
lar one. It is well to disabuse the mind of this impression 
at the start, as there is a form of the disease that is dry 
throughout — the erythematous form. There are five forms 
of eczema, known as the erythematous, papular, vesicular, 
pustular, and squamous. Eczema madidans is but a con- 
venient term to describe a very moist eczema. Eczema 
rimosum or rhagadiforme is but an eczema in which there 
is cracking of the skin, especially about the joints. Unna 
has recently introduced the term eczema seborrhoicum, 
which, though it has not yet taken a secure place in the 
family, has won so much notice that it merits a special 
description. 

Before discussing each of these forms by itself, it is 
necessary to understand that no one of them, excepting 
perhaps eczema erythematosum, is clear cut and unchang- 
ing. On the contrary, the disease may begin as a papular 
erythema ; upon the papules vesicles may form which will 
run together and soon break down of themselves and form 
a weeping patch ; the subsequent lesions may then be pus- 
tules, and the final stage through which all varieties pass 
before recovery is the squamous. Now we are ready to 
study each variety by itself. 

Eczema erythematosum is most often encountered upon 
the face of an adult, though it may occur elsewhere and in 
children. Beginning as one or more ill-defined red patches, 



ECZEMA. 185 

it soon forms a continuous patch by the coalescence of the 
smaller ones. Sometimes the whole face is involved, some- 
times there are several patches. The inflammation is often 
attended by oedema to such an extent that the eyes are 
nearly closed if the disease is in their neighborhood. The 
patient experiences great discomfort on account of the 
burning and stiffness of the skin. The skin feels harsh, 
dry, and thickened ; it is swollen ; its color is bright or 
dull-red ; and there is a alight amount of small adherent 
scales. If it occurs on contiguous folds of skin, there may 
be moisture. Upon the face vesicles may develop, but this 
is exceptional. After lasting for a time the symptoms may 
subside, and recovery take place, the patches fading away 
altogether and not in the center alone. It may assume a 
chronic form and last for years. It is seen at times upon 
the body in the form of very superficial, pale-red, scaly, 
round, circumscribed patches, and constitutes one form of 
the so-called parasitic eczema. 

Eczema papillosum. This is the lichen simplex of the 
old writers. It consists in an eruption of pin-point to 
pinhead, bright or dull-red, acuminate, discrete, grouped, 
or perhaps confluent papules. Very frequently the papules 
are capped by vesicles. The papules may remain discrete 
throughout their course with an occasional small confluent 
patch to betray the nature of the disease. This is one of 
the most itchy varieties of this pruriginous disease, and 
the scratching consequent upon it produces excoriations, 
and, breaking down the vesicles and papules, gives exit 
to the serum, and converts the patch into a moist one. 
This variety is located preferably on the extensor aspects 
of the limbs. The life of the individual papule is com- 
paratively long — days or weeks. It is often obstinate to 
treatment. 

Eczema veszculosum is the most common and most char- 
acteristic form, and consists in an eruption of pin-point 
to pinhead, rounded or acuminate vesicles that appear 
upon a reddened surface in immense numbers. Prickling 
and tingling precede the outbreak ; intense itching, and 



186 DISEASES OF THE SKIN. 

more or less swelling attend it. The vesicles group, and 
perhaps coalesce, and soon rupture of themselves, and 
discharge a clear, sticky, mucilaginous fluid that possesses 
the quality of stiffening and staining linen, and dries into 
a light-yellow crust. The vesicles rupture so early that 
it is rare for the physician to see a case with the vesicles 
intact. New vesicles form about the patch, and break 
down ; the discharge continues from the sites of the vesi- 
cles, and the crust continuously forms. A raw surface is 
exposed when the crusts are removed. Sometimes when 
the crust is prevented from forming on account of fric- 
tion, there is a weeping surface which has been called 
eczema madidans or rubrum. Eventually the discharge 
ceases, the hyperemia lessens, scaling takes place, and after 
a time the skin returns to its normal condition. This 
form of eczema seeks the soft parts of the skin, the flex- 
ures of the joints, the flexor surfaces of the limbs, and 
behind the ears. It may involve the whole or nearly the 
whole cutaneous surface. After it has lasted a little while 
in a part the skin is evidently thickened. With it papules 
and pustules very generally are found. 

Eczema pustulosum. Under this head many authors, 
notably the Vienna school, place all cases of impetigo. 
Like the pustular syphilide, this form of eczema occurs in 
more or less broken down, cachectic, delicate, or strumous 
subjects. It is the most common form of eczema met with 
in children, and in them occurs by preference on the face 
and head. The eruption consists of small pustules that 
may start as pustules or develop from vesicles. They are 
present in large numbers, and tend to break down and 
form patches covered with greenish crusts. If blood is 
drawn by scratching, the crust will be blackish. They 
are somewhat larger than the characteristic vesicles, and 
have a fondness for hairy parts, though any part of the 
body may be affected. This and the previous form often 
merge into each other. It is not so itchy as the other 
forms. It may change into an eczema madidans, and it 
passes through the squamous stage on the way to recovery. 



ECZEMA. 187 

Eczema squamosum is the final stage through which all 
cases pass on their way to recovery. In it the skin is dry, 
red, and covered with thin, papery, flat, large or small 
scales. It is a condition of the skin in which the forma- 
tion of its corneous layer falls short of perfection. The 
disease maj continue in this condition for an indefinite 
time, a chronic eczema, with occasional exacerbations. 
Then it may pass away entirely and the skin become quite 
well ; or some local injury may cause an acute outbreak of 
eczema. The skin in this form is more or less thickened, 
and deep cracks are liable to form about the joints, be- 
cause the infiltration of the skin interferes with its elas- 
ticity, and it breaks instead of stretching when the joint 
is extended. While the patches are usually ill defined, 
in some cases they will be round, and with well-marked 
borders. This form is spoken of as orbicular eczema. 

Eczema may be acute or chronic — terms that apply not 
to the length of time that the disease has lasted, but to 
the symptoms it presents. It predisposes to ulceration 
upon the legs when combined with varicose veins, and 
then is named eczema varicosum. This must not be con- 
founded with a somewhat similarly sounding name, eczema 
verrucosum, which is a rare form, in which the skin takes 
on a warty appearance on account of a hypertrophy of 
the papilla?. 

Etiology. Like its symptoms, its causes are numer- 
ous. It may arise from purely local causes, but even then 
it is probable that we should assume, in most cases, a pre- 
disposition on the part of the skin. Thus, we have ec- 
zema of the hands in washerwomen. Perhaps for a score 
of years they had washed in the same water and with the 
same soap without eczema. Then under the same local 
conditions, but with some unknown internal constitutional 
state, an eczema breaks out. Of external irritants we 
have the sun, water, intense artificial heat, acids, al- 
kalies, traumatism, rubbing of opposed surfaces or chafing 
by the clothing, parasites ; in fact, just the same things 
as will cause a dermatitis, only now the action goes fur- 



188 DISEASES OF THE SKIN. 

ther, and a catarrhal condition of the skin results. Cold 
has an undoubted influence on the skin, and eczema is 
more common in winter than in summer, and is generally 
aggravated by extremely low temperature, even when the 
patient keeps in the house. It has been observed that 
children with eczema grow worse when it is cold and a 
high wind is blowing, even though they are not exposed 
directly to these conditions. Vaccination may act as a 
local cause. 

Of the internal or predisposing causes, perhaps the most 
common and active is some digestive or intestinal disturb- 
ance — it may be dyspepsia or malassimilation, or de- 
rangement of the liver, or constipation. At other times 
the kidneys are at fault. Diabetes and Bright's disease 
both predispose to eczema. Chlorosis and ansemia, uter- 
ine disorders and the menopause, and the strumous dia- 
thesis, are at times active factors. Derangements of the 
nervous system are exciting causes ; now and again we 
will meet with cases which appear suddenly after some 
nervous shock. Rheumatism and gout and varicose veins 
are other predisposing causes. To most of these internal 
causes some external cause must be added before the 
eczema appears. 

The French school of dermatology has long held to its 
theory of diathesis, and has taught that the dartrous di- 
athesis is the cause of eczema. Outside of France little 
is known about diathesis. A vulnerability of the skin is 
necessary for the production of an eczema, and many 
patients may fairly be regarded as eczematous, just as 
others may be spoken of as gouty, or rheumatic, or psori- 
atic. This peculiarity or tendency of the skin may be 
inherited, and in so far eczema may be regarded as hered- 
itary. 

The disease attacks all ages, conditions, races, and both 
sexes, and is the dermatosis we are most often called upon 
to treat. It is especially common in children. In Bulk- 
ley's tables, out of 3,000 cases, 676 occurred under five 
years of age, and of these 520 were in children under 



ECZEMA. 189 

three years. Of the remaining cases 1,234 were between 
the ages of twenty and fifty, and were divided about 
equally in each decade. About one-third of all skin dis- 
eases are eczema. 

These many etiological factors indicate that it is prob- 
able that our present eczema is a too composite disease, 
and it is for this reason that attempts are constantly made 
to take away certain members of the family and form them 
into separate diseases. Unna and others have asserted 
of late that a parasite, yet undiscovered, is the cause of 
one variety of eczema, his Eczema seborrhoicnm. Unna 
further teaches that there are two other varieties of the 
disease, one due to reflex nervous irritation, such as is 
seen during dentition of infants, and one dependent upon 
the tubercular diathesis. 

Pathology. Eczema is a catarrhal inflammation of 
the skin, analogous to that of the mucous membrane, 
which has its seat principally in the papillary layer of 
the skin and in the rete. This superficial location of the 
disease is the reason why the skin is left unmarked after 
the disease has been recovered from. A tropho-neurosis 
is supposed by many to be the cause of the disease when 
not due to local irritants, and Crocker quotes Marcacci as 
having found changes in the sympathetic in a fatal case of 
universal eczema. 

Diagnosis. If the six prominent symptoms of eczema 
are remembered, namely, redness, itching, infiltration or 
thickening, exudation or tendency to moisture, crusting or 
scaling, and cracking, it will be a great aid in diagnosis. 
To them should be added the tendency the disease evinces 
to locate in the folds of the joints, between apposed sur- 
faces of skin and behind the ears, and the peculiar 
mucilaginous quality of the exudate, which stiffens and 
stains linen and glues the hair together. Fortunately, a 
diagnosis of eczema will fit one out of every three cases. 
Here will be given the general diagnosis, reserving for the 
sections on regional eczema the diagnosis of special forms 
where necessary. 



190 DISEASES OF THE SKIN. 

Dermatitis is often distinguished with difficulty from 
eczema, and frequently runs over into it. As a rule, it 
runs a more rapid course, its vesicles are longer preserved, 
bullae are apt to form, there is burning rather than itching, 
and it heals readily on removal of the cause. 

Dermatitis exfoliativa is, when fully developed, a uni- 
versal eruption, while eczema is very rarely so. It is also 
dry, and has abundant large scales, while eczema will ex- 
hibit moisture somewhere, and does not scale so abun- 
dantly. For further points in diagnosis, see under Derma- 
titis exfoliativa. 

Erysipelas is attended by fever and marked constitu- 
tional disturbances, has a sharply defined border, advances 
steadily at its margin, and forms a swollen, deep-red patch 
upon which large vesicles and bullae form. The margin 
of eczema is ill-defined, fading off into the surrounding 
skin ; its vesicles are pin-point to pinhead size, and there 
is little or no constitutional disturbance. Eczema has a 
dry, rough surface in the erythematous form, while ery- 
sipelas "has at first a smooth and shining one. 

Erythema burns rather than itches ; its redness can be 
entirely squeezed out by pressure, leaving a whitish spot, 
and returns promptly when the pressure is removed. In 
eczema pressure will cause the redness to disappear, but it 
will leave a yellow stain in its place. Erythema lacks the 
itching, exudation, scaling or crusting, and cracking of 
eczema, and is prone to appear upon the backs of the 
hands and wrists, and is symmetrical. 

Herpes febrilis resembles eczema only in having vesicles 
upon a red surface. It occurs usually in a single patch 
upon the face ; its vesicles are discrete, and show no tend- 
ency to run together ; its course is short, and it pains or 
burns, but does not itch. 

Zoster occurs in the form of a number of herpetic patches 
following the course of a nerve, and occupying only one 
side of the body — symptoms that are entirely foreign to 
eczema. 

Impetigo contagiosa occurs for the most part upon the 



ECZEMA. 191 

face, hands; and exposed parts. Its pustules are large, 
flat, and discrete, not small and conglomerate. Its crusts 
are thin and stuck on, not greenish and thick, as in eczema. 
It is a vesico-pustular disease, and often presents large 
vesicles or bulla? that look like burns of the second degree. 

Lichen ruber and Pemphigus foliacms do bear some 
resemblance to eczema erythematosum when generalized. 
But the history of these two is quite different from that 
of eczema. 

Phthiriasis or pediculosis shows parallel scratch marks 
over the shoulders and excoriations about the waist and 
on the limbs where the seams of the clothing come. If on 
the head, the lesions will be on the occiput, and nits will 
be found on the hair of that region, or of the temples. 
The eruption to which they give rise is an eczema, but 
the cause of it is evident. 

Pruritus cutaneous has no lesions, properly speaking, 
and the excoriations met with are not in patches, but scat- 
tered all over the body at intervals and irregularly. The 
itching is more paroxysmal than it is in eczema, and the 
itching is the only symptom that it has in common with 
eczema. 

Psoriasis, when occurring in typical round, or oval, 
sharply defined patches, with silvery scales, offers no dif- 
ficulty in diagnosis from a typical eczema. From circum- 
scribed eczema, that occurs occasionally, it may be diag- 
nosticated by the color — of a brighter red ; by the scaling, 
that is whiter, thicker, and more laminated, and by find- 
ing characteristic patches either of the one or the other 
disease elsewhere on the body. When psoriasis occurs in 
large areas it is diagnosticated from squamous eczema by 
its sharply defined border ; its marginate form ; its brighter 
red ; its more abundant, thicker and whiter scales ; its fond- 
ness for the extensor surfaces of the limbs, while eczema 
seeks the flexor aspects and the flexures of the joints ; its 
•uniform character and constant dryness, against the poly- 
morphous character of eczema and its moisture ; and its 



192 DISEASES OF THE SKIN. 

history of frequent relapses, always of the same sort and 
always on the elbows and knees. 

Rosacea occupies the middle third of the face from 
above downward, attacking the forehead, nose, and chin, 
while eczema affects the whole or part of the face, but 
never occurs on these limited regions alone ; it burns 
rather than itches ; it shows telangiectases, and its red- 
ness and occasional discrete, sluggish, superficial pustules 
are very different from either the dry, harsh, scaly red- 
ness of an erythematous eczema, or the crusted surface of 
a pustular eczema. 

Scabies may be diagnosticated from eczema by its loca- 
tion upon the anterior surface of the wrists, between the 
fingers, and upon the abdomen and buttocks of both sexes, 
and upon the nipples and breasts of women, and the penis 
of men. In children the feet are often affected. The 
presence of cuniculi is diagnostic, but they are hard to 
find in some cases. Of course, the eruption in scabies is 
an eczema ; but it is important to recognize, where pos- 
sible, the cause of an eczema in order to cure it. 

Syphilis, like eczema, is a protean disease, but it does 
not itch, and that is an important point in differential di- 
agnosis. It is true that occasionally a papular syphilide 
does itch, but the occurrence is so rare that it need not 
here be taken into account. The early syphilides are 
general eruptions, whether macular, papular, or pustular, 
and the efflorescences never form patches, though they 
may show more or less grouping. When the other symp- 
toms of syphilis are present, such as the initial lesion, 
mucous patches, and alopecia, there can be no difficulty. 
It is the later manifestations of the disease that offer dif- 
ficulties in diagnosis, and especially the grouped papular 
lesions that occur on the palms in the form of scaly 
patches. In some cases a diagnosis is impossible. The 
most suggestive symptom of syphilis is the occurrence of 
the disease upon the palm of one hand alone. The patch 
will have a wavy outline ; will be scaly, but not moist or 
crusted ; will often show healthy skin in the middle ; and 



ECZEMA. 193 

there are apt to be isolated, scaly, dark-red papules some- 
where in the neighborhood. The finding of scars of old 
lesions, or some other evidence of syphilis, will aid us. 

Trichophytosis corporis when in disk-shaped patches 
that have not formed rings bears at times so close a re- 
semblance to eczema that it is difficult to make a diag- 
nosis at once. But in a short time the center of the disk 
will clear up and the annular ringworm patch will declare 
itself. Eczema does not have annular patches. 

Urticaria, when it has induced itching and has been 
scratched, looks like an eczema. We recognize it by the 
finding of the wheals, or the history of them, and by the 
isolated, scattered distribution of the excoriations and 
papules. Some cases of papular urticaria can only be di- 
agnosticated after prolonged observation. 

Teeatment. AVhile not a few cases of eczema arise 
from purely local causes, and require only external treat- 
ment, in most cases the patient is not in good condition, 
and he needs treatment quite apart from his skin disease. 
It is well for us to begin our treatment of a case by re- 
garding it as one of a sick man rather than a sick skin. 
The better practitioner of medicine a man is, the better 
his chances of curing his case will be. It is not the part 
of the writer on matters dermatological to instruct his 
readers in general medicine, and here I can give only an 
outline of the treatment proper to be followed. 

If the patient is anaemic, we should administer iron, 
and see that he has plenty of fresh air and a sufficient 
amount of exercise. If he is run down, and especially if 
he is of a strumous habit, cod-liver oil will be indicated. 
To the nervous patient, strychnine, hypophosphites, and 
other nerve tonics should be administered. The dys- 
peptic needs mineral acids, mix vomica, pepsine, or bis- 
muth and soda, according to the different form the trouble 
takes. Those suffering from uterine diseases need the 
treatment best suited to their case. The gouty and rheu- 
matic will be benefited by alkalies, such as the acetate of 
potash or the phosphate of sodium. Colchicum will be 
13 



194 DISEASES OF THE SKIN. 

useful in gouty cases. In fact, there is no specific for 
eczema, and each case should, be studied and treated by 
itself. 

But nearly every case requires attention to the diet and 
exercise, and to the proper action of the bowels and 
kidneys. The diet is of special importance. Piffard x 
has found that 56 per cent, of his cases of eczema have 
been carnivorous — that is, eating meat three times a day 
and but little bread and vegetables ; 40 per cent, om- 
nivorous, and but 4 per cent, herbivorous. Many of the 
patients eat too much and exercise too little. Many suffer 
from distress of stomach after eating certain articles. 
Some eat too little and that of improper sort. The indi- 
cations for treatment are therefore obvious. The greatest 
difficulty we have to contend with is the objection most 
people have to dieting of any sort. 

In an acute eczema of any considerable extent it is al- 
ways best to put the patient on a restricted and simple 
diet, and of these, where milk is well borne, a milk diet 
is the best. Two or more quarts of milk may be taken 
during the day in divided doses, with dry toast or toasted 
crackers. After a few days a more liberal diet may be 
allowed, as in subacute and chronic eczema. 

In subacute and chronic eczema meat should be taken 
but once a day, and should be beef, mutton, or chicken, 
and these should be eaten in the middle of the day when 
possible. Breakfast and supper should be very simple, of 
crackers and milk, bread and milk, or some of the grains 
well cooked and eaten without sugar. Fish may be al- 
lowed, but not those with dark meat, or oily. An occa- 
sional egg may be eaten in the morning, but not every 
day. ~No pastry, cake, or confectionery should be al- 
lowed. Apart from absolute simplicity, the patient's 
taste may be consulted, care being taken to avoid any- 
thing that he knows will disagree with him. It is a good 
rule to tell the patient that he may eat what he likes, but 

1 Materia Medica and Therapeutics of the Skin. Win. Wood & Co., 
K Y., 1881. 



ECZEMA. 195 

not of more than three dishes at a meal. It is unlikely 
that he will then overeat. Those who eat too little for 
any reason should be directed to take that little more often 
during the day. The dyspeptic should drink a cup of hot 
water about a half hour before meals. In these cases it 
is sometimes necessary for a time to resort to kumyss or 
matzoon, and artificially digested foods, but the sooner he 
can return with comfort to a more natural diet the better. 
Fried and warmed-up meats should be avoided in all cases. 
Fruits fully ripe or stewed can as a rule be liberally par- 
taken of. 

All alcoholic drinks must be absolutely forbidden. 
Malt liquors are especially obnoxious to all irritable skins. 
Tea, coffee, and chocolate are best let alone. Coffee, one 
small cup, may be allowed for breakfast ; or cocoa, which 
is better, if made with a good deal of milk. Water should 
be drunk regularly, and it is not unlikely that much of 
the benefit derived from visiting foreign spas is on ac- 
count of the regular drinking of water. A good rule is 
for the patient to driuk a glass of water before meals, 
while dressing, a glass of water or other fluid at each 
meal, a glass of water about two hours after meals, and 
before going to bed. If preferred, bottled table waters 
may be used. Vichy water may be substituted for plain 
water once or twice a day. Tobacco is harmful in some 
cases. 

Enforcement of these dietary laws will in many cases 
overcome constipation. It is best not to resort to medi- 
cines to procure a good daily movement of the bowels, if 
it can be avoided. Kneading of the bowels when in a 
recumbent position will often stand us in good stead, the 
bowels being steadily and deeply rubbed with the heel of 
the hand, starting in the right groin, and following the 
course of the large intestine upward, across, and down- 
ward. The habit of going; to stool at a regular hour of 
the day should be formed, and it should be seen to that 
the bowels act promptly. If we must needs give medi- 
cine, the tablet triturates of aloin, belladonna, and nux 



196 DISEASES OF THE SKIN. 

vomica ; the pill of iron and aloes ; the extract of cascara 
sagrada, with or without mix vomica, which may be ad- 
ministered in capsules to avoid the disagreeable taste ; 
Startin's mixture — 

R 



M. 



Magnesii sulphatis, 
Ferri sulphatis, 
Ac. sulphur, dil., 




gyj-SJss; 

o.i; 

5ij; 


20-30 
3 
6 


Syr. pruni virgin., 
Aqua?, 


ad 


Si; 


24 
100 



Sig. A teaspoonful through a tube, after meals. 



or any other serviceable remedy may be given. Harda- 
way recommends the phosphate of sodium, a teaspoonful 
in hot water before breakfast, or three times a day, for 
lithsemic patients who are constipated. This is an excel- 
lent laxative for children, a little of it being put into their 
milk, to which it gives a hardly noticeable salty taste. 

Exercise in the open air is as necessary for our eczema- 
tous patients as for any other class. It should not be 
taken so as to cause over-fatigue. Patients with eczema 
on the face and hands, or with a tendency thereto, should 
always wear gloves during the cold seasons, and should 
always protect the skin of the face by a little powder or 
vaseline before going out into the cold, or storm of wind 
or rain. 

Though there is no specific for eczema, there are certain 
drugs that have acted favorably upon the disease in the 
hands of some observers. Arsenic has come down from 
old with a reputation for curing eczema, and is largely pre- 
scribed. It had best be let alone. It is only of benefit in 
chronic scaling cases, and in only a few of them. It may 
be used in the form of Fowler's solution (Liq. potassii 
arsenitis), giving from 2 to 5 minims well diluted, three 
times a day, after meals ; or as arsenious acid, in tablet 
triturates, either with or without pepper, dose -g 1 ^ to gL- 
grain. The wine of antimony in 5-minim doses, three 
times a day, has been warmly commended. Phosphorus, 
TFo to TF g ram > either in pill or in oil, has been found 
useful in long-standing eczema. Piffard speaks well of 



ECZEMA. 197 

an infusion of Viola tricolor in acute or chronic eczema 
capitis, especially in lymphatic children. It is made by 
putting one or two drachms of the imported herb into a 
bowl, pouring a pint of hot water over it, and covering 
with a plate. When cool, it is to be taken in divided 
doses during the day. After a few days it generally ag- 
gravates the disease, a good thing to accomplish in chronic 
cases. It is then to be discontinued for a few days or a 
week. In acute cases the dose should be quite small. In 
infants one drop two or three times a day is often suffi- 
cient. Adults may take as much as a teaspoonful in 
chronic, sluggish cases. Turpentine, the spirits, is recom- 
mended by Crocker in obstinate cases. It is given in an 
emulsion with mucilage, three times a day, after meals, 
the dose being 10 minims at first, and then, if tolerated, 
increased by 5-minim doses up to 20 or 30 minims. 
While it is being taken, not less than a quart of barley- 
water should be drunk, and the last dose should be taken 
not later than six o'clock in the evening. The same 
author recommends counter-irritation over the spine, the 
nape of the neck for eczema of the upper half of the body, 
and over the last dorsal and first lumbar vertebrae for the 
lower half. Dry heat, a mustard-leaf, or liquor epispas- 
ticus, may be used. I have seen most excellent effects 
from this plan. The spinal ice-bag sometimes accom- 
plishes the same result. 

In acute eczema, if taken early, sharp catharsis will 
sometimes tend to lessen the severity of the attack by re- 
ducing the congestion of the skin. In chronic eczema, 
even without evident renal derangement, the acetate of 
potash in 15-grain doses will prove useful. The itching 
may be so severe in some cases that even our local reme- 
dies may not allay it, and it may seem necessary to give 
some medicine to procure sleep. Never use opium. The 
bromides, chloral, or phenacetin may be given. Bulkley 
recommends tincture of gelsemium, of which ten drops 
are to be given, and repeated and increased every half- 
hour till relief is obtained, or constitutional symptoms of 



198 DISEASES OF THE SKIN. 

languor, tranquility, dizziness, impairment of vision, and 
drooping of the lids, are produced. Quinine, in J-grain 
to 15-grain dose given at bedtime, is commended by some 
for the same purpose. 

Local Treatment. In all cases, whether due to 
purely local causes or a combination of these and some 
general cause, local treatment is of the greatest impor- 
tance. The books teem with prescriptions which have 
been found efficacious, and some of them contain so many 
ingredients that it is hard to determine with exactness to 
what the benefit is due. After all, the matter is very 
simple, and, if the principles are mastered, little difficulty 
will be found in accomplishing the desired end. In acute 
cases, where we have heat and swelling, employ soothing 
remedies ; in subacute cases, where the swelling has subsided 
and where the papulation, vesiculation, pustulation, or exuda- 
tion is more or less active, use astringent and slightly stimu- 
lating remedies ; in chronic cases, where we have thickening 
with scaling, stimulate; in all cases protect the shin from ex- 
ternal irritation. It is better to learn how to use a -few 
remedies and to know what to expect from them than to 
try every new method that appears in the medical press. 

It is a good, broad rule that water should not be used 
on an eczematous skin, as it removes the newly formed 
epidermis and exposes the tender skin to the air. In all 
but chronic cases it should be used sparingly, and only to 
remove dirt, or crusts, or scales, and the skin should be 
at once covered with some protecting powder or ointment. 
If water is used it should be either rain or boiled water, 
or water with a little soda, one drachm to the basinful, or 
bran in it. Often it is better to clean the skin with an 
oily lotion than to use water. 

In acute eczema lime-water, liquor plumbi subacetatis 
dil., lead and opium wash, or solutions of borax or soda, 
0:10 or two drachms to the pint, may be sopped on three 
or four times a day, dusted over with cornstarch, bis- 
muth, lycopodium, kaolin, or French chalk, and covered 
with light, old linen or muslin. All these will allay the 



ECZEMA. 199 

itching, but if this is especially severe the following may 
be used : 

R • Camphori, 
Zinci oxidi, 
Arnyli, 

Startin recommends the following 



oi.i ; 


31 

15 

ad 30| 


M. 


T I 

S ss ; 

SJ; 
5 Y1 J 


' 6 i 
2 

12 

ad 100 


M. 



R • Zinci oxidi, 

Pulv. calamina? prep. , 

Glvcerini, 

Liq. calcis, 

As soon as the early and most acute stage is passed, 
that is, in the subacute eczema, a protecting and soothing 
ointment is to be used, and of these no one is safer than 
the standard benzoated oxide of zinc ointment that usu- 
ally can be obtained anywhere. The cucumber ointment 
is also soothing. If the case be one in which there is 
much discharge, as in pustular, vesicular, and weeping 
eczemas, Lassar's paste is better than the oxide of zinc 
ointment, as being a paste it allows the discharge to per- 
colate through it. It is made as follows : 

B. |>™di,} 5a 5 ... 

Vaselini, gss ; 16| M. 

The addition of 10 or 15 grains of salicylic acid to the 
ounce increases its anti-pruritic quality. The only diffi- 
culty is that it takes time and muscle to make, and but 
few druggists make it well. See that in it, as in all other 
ointments, there are no gritty particles left. All ointments 
must be smooth, or they do harm rather than good. In 
using ointments in eczema they should be evenly spread 
upon cheese cloth folded four times, or upon old linen or 
muslin, in a layer as thick as the back of a table knife 
blade, applied to the affected part and bound down snugly 
with a bandage. They should be changed twice a day, 
or more often if the discharges are profuse. 

Painting a limited moist patch of eczema with a solution 



200 DISEASES OF TEE SKIN. 

of nitrate of silver, 3 to 10 grains to the ounce, is often a 
most prompt method of curing the disease. 

Ointments are objectionable on account of their greasi- 
ness, and where possible it is pleasanter to use lotions. 
Of these one of 



B 



Calamin. , 


9ij; 


10 


Zinci oxid., 


5ss; 


6 


Glycerini, 


n\xv; 


3 


Liq. amygdalae co., 


SJ; 


100 



M. 



answers well. Peroxide of hydrogen sopped on exercises 
a beneficial effect on pustulation. 

The diachylon ointment will often prove beneficial, es- 
pecially after the subsidence of acute symptoms. It is 
best used diluted with ungt. aquae rosse in the proportion 
of two parts to one. Most cases that we are called upon 
to treat are in or near to the subacute stage, as the acute 
stage soon passes off. It is always advisable to begin 
treatment not too boldly. If our protecting and astrin- 
gent remedies do not cure the case after a fair trial, then 
we must add stimulants, and of these one of the most re- 
liable is tar, adding it at first in the proportion of about 
fifteen drops of the oil of cade to the ounce of ointment- 
base, such as oxide of zinc ointment. 

In chronic squamous eczema we need stimulation to whip 
up the circulation, to produce absorption of the infiltra- 
tion of the skin, and to promote a return to health. Here 
tar is one of our most reliable remedies, and it can be 
used in various strengths and ways. We may use the oil 
of cade, oleum cadini, the oil of birch, oleum rusci, or pix 
liquida, There are some doubt and difficulty about ob- 
taining genuine oleum rusci, which is largely used by 
tanners in the preparation of Russia leather. The oil. of 
cade is most used. Some prefer this ointment : 

B . 01. cadini, 3ss-j ; \ -- 2-4 

Zinci oxidi, 5 ss_ j 5 / 

Unguenti aquse rosse, gj ; 30 M. 

Or the cade may be added to the oxide of zinc ointment 



ECZEMA. 201 

in the proportion of a drachm to the ounce. Or pix 
liquida may be substituted in about double the strength. 

Another most excellent way of using tar, and prefera- 
ble to the latter because not so liable to stain the clothing, 
is that proposed by Pick, namely ; To make a strong 
tincture of tar, using 40 points of pix liquida to 20 parts 
of alcohol. To paint the part every night with three 
coats of this tincture, letting each coat dry ou before an- 
other is applied. Then cover with oxide of zinc oint- 
ment ; the ointment being changed morning and night. 

Bnlkley in some cases recommends tar in what he names 
liquor picis alkalinus, which is made as follows : 



R 



Picis liquids, 


Sy; 


25 


Potass, causticse, 


Si; 


12 


Aquae, 


Sv; 


ad 100 



M. 



Dissolve the potash in the water and add slowly to the 
tar in a mortar with friction. This is to be used diluted 
twenty or more times with water, and followed by oxide 
of zinc ointment. 

In some very chronic, thickened eczemas the tar may be 
rubbed in pure. If the eczema is very extensive, the tar 
may be used in olive oil or cotton-seed oil and smeared over 
the body. In some cases the tar will give rise to systemic 
poisoning, the urine will become black, and the patient will 
suffer from headache, oppression, nausea, vomiting, and 
diarrhoea, and the pulse will become frequent. Of course, 
under these circumstances the tar must be stopped. 

Sulphur is, next to tar, one of our best stimulating 
remedies in squamous eczema. It is not so reliable, as it 
is more uncertain in its effects. It finds its best use in 
circumscribed patches, and may be used in vaseline or 
simple ointment in the strength of one or two drachms to 
the ounce. In some skins it produces a good deal of 
dermatitis. 

Green soap is often of the greatest service in chronic 
eczema. It is to be used in the following way : Take 
either the green soap or Bagoe's prepared olive soap ; 



202 DISEASES OF THE SKIN. 

warm water ; and oxide of zinc ointment spread on mus- 
lin or linen. Dip a piece of flannel in the soap and then 
in the water, and then with it scrub the parts vigorously 
until all the scales are removed and the skin looks some- 
what raw. Now wash off all the soap with plenty of water, 
dab the part dry with a soft towel, immediately cover with 
the ointment, and apply a bandage. The soap is to be 
used once a day and the ointment changed twice a day. 

Caustic potash, 15 grains to 1 drachm to the ounce ; or 
salicylic acid, 10 to 15 per cent., in ether may be used to 
reduce very much thickened patches. Nitrate of silver, 
10 to 15 grains to the ounce, may also be used. 

Unguent, hydrarg. ammoniat., diluted to half its strength, 
is of use in chronic eczema of limited area. 

Ichthyol and resorcin are two of the more recent addi- 
tions to our armamentarium. The former has a more 
disagreeable odor than tar, and as Crocker says of it : 
" We do not want more of such remedies, as tar fills that 
place so w r ell ; what is required are remedies which do 
not stain nor smell." Resorcin in from 2 to 5 per cent, 
strength is a good stimulating application. 

For the reduction of infiltration and removing the scales 
in a chronic eczema nothing is better for a time than sheet 
rubber applied to the part and bound down with a roller 
bandage. The rubber should be removed once a day, 
sponged off with soda and water, and reapplied. The re- 
lief to the itching procured by this means is sometimes 
surprising. As soon as the infiltration is reduced we 
should resort to our tar remedies for completion of the 
cure. 

Many attempts have been made to find a substitute for 
greasy or oily applications in the treatment of skin dis- 
eases. Thus we have the plaster mulls of Unna, in which 
a plaster mass is incorporated with the mulls. Many 
speak loudly in their praise. Then collodion and trauma- 
ticine have been used, and answer well, the tar, salicylic 
acid, or what not, being dissolved or held in suspension. 
In this way chrysarobin may be used on limited patches 



ECZEMA. 203 

of chronic eczema. Gelatin preparations are very valu- 
able and applied either to a subacute or chronic patch, 
especially when there is no moisture, will allay the itch- 
ing and hasten the cure. Unna's gelatine paste sets at 
once. It is composed of 

R . Zinci oxidi, 30. 

Gelatini, 30. 

Glycerini, 39. 

Aquse, 10. M. 

It forms a hard mass that must be melted before it is 
used. The best way to use it is to put it in a small tin 
saucepan that fits into another pan that holds water, such 
as is used for sterilizing milk or cooking oatmeal gruel. 
This can be heated over a bnnsen burner or spirit lamp. 
When melted and still warm it is to be painted over the 
part under treatment by means of a wide paint brush. 
Immediately over it place a layer of absorbent cotton and 
over all a roller bandage. This dressing may be left on 
for two or three days. The gelatin may be used as an 
excipient. Bassorin paste and jrfasment have been recently 
brought out, and promise well. 3Iedicated soaps have 
their advocates. I have had no experience with the last. 

In the treatment of eczema we must not content our- 
selves by simply giving our patient an ointment, but we 
must instruct him in the way he should use it. As a 
rule, and where possible, our ointments should not be 
smeared on the skin, but spread on old linen, muslin, or 
the like, and bound down with a bandage or with a ring 
of elastic webbing. In chronic patches it is well to rub 
in our tar or other ointment. 

Massage sometimes does good service in reducing infil- 
tration, the part being stroked upward in the course of the 
circulation. 

Baths are not usually advisable in eczema, and are ap- 
plicable only to chronic cases. Good results have been 
reported from some sulphur baths. Residence at the sea- 
side generally proves bad for eczematous patients, but it 



204 DISEASES OF THE SKIN. 

may be a good thing for some run-down patients, the tonic 
effect of the sea air out-balancing the evil effect' of the 
dampness. Soda, borax, or bran baths will prove grateful 
in some cases. Bulkley orders the following : 

R. Potass, carbonat., %ir. 130 

Sodii carbonat, giij. 100 

Boracis pulveris, gij. 70 M. 

Add to thirty -gallon bath with half a pound of starch. 

Prognosis. We can give assurance of curing eczema 
so far as the attack with which the patient comes to us is 
concerned. We can give no positive assurance that the 
disease will not return. The cure of the attack requires 
patience, careful study of the case, and the intelligent use 
of remedies. But there are some cases that are exceed- 
ingly rebellious. We have to accept the fact that some 
people are " eczematous," and that they cannot be perma- 
nently cured unless they are regenerated. We should cure 
our cases as rapidly as possible, and not take refuge in the 
excuse of the incompetent man and tell the patient that it 
is dangerous to cure it. 

We must now consider Regional Eczema. 

Eczema Ani, as usually met with, is of the squamous, 
thickened variety with fissuring. It may also be moist. 
It usually extends up the whole inter natal fold. It gives 
rise to great pain in defecation and to much itching at all 
times. The discharge from this form, as well as from 
eczema of the genitals, is frequently offensive. Excessive 
use of tobacco predisposes to this variety of eczema, prob- 
ably on account of the nervous irritation inducing itching, 
for the relief of which the patient scratches and produces 
the eczema. 

In treatment the first thing is to stop the use of tobacco, 
a hard task, as the patient is ofttimes incredulous of its 
efficacy. Horseback-riding and much walking will some- 
times have to be stopped, as they may aggravate the 
trouble. If hemorrhoids or fissures of the mucous mem- 
brane are present, as they quite frequently are, they must 



REGIONAL ECZEMA. 205 

be cured in order to obtain a permanent cure of the 
eczema. The bowels must be kept easy by laxatives so 
that one soft movement may be had each day. Liver 
derangements must be corrected to prevent portal conges- 
tion, and dieting will be of service. The nates must be 
separated by folds of lint, and the parts kept scrupulously 
clean, though water should be used as sparingly as possi- 
ble. The itching may be relieved by sopping on hot 
water, dabbing the part dry, and making the chosen ap- 
plication. Tar or diachylon ointment may be used, all 
covered in with a dusting powder. Usually the drier the 
parts can be kept and the less ointment is used the better. 
Painting a limited surface with salicylic acid, 10 to 15 
grains in an ounce of flexible collodion, is often followed 
by the happiest results. Painting with nitrate of silver, 
10 to 15 grains to the ounce, is sometimes advisable. 
Here, too, if there is much thickening, wearing rubber 
cloth for a few days will greatly hasten the cure. A 
well-applied T-bandage is the best way of keeping the 
dressings in place. 

Eczema Aurium. Eczema may aifect both the ear itself 
and the inside of the auditory canal. AVhen the ear is 
acutely affected it is swollen at times so much as to stand 
out from the head. In acute eczema of the external audi- 
tory canal, which is secondary to that of the auricle, the 
swelling may be so great as to cause dulness, if not loss 
of hearing. Of eczema of the outer part of the ear noth- 
ing special need be said excepting that the dressings must 
be exactly applied to all the little furrows of the ear, and 
a pledget of lint placed in the furrow behind the ear, thus 
separating it from the side of the head, so that in sleeping 
the two surfaces of skin do not come in contact. Paint- 
ing this part of the ear with a solution of nitrate of silver, 
ten grains to the ounce, will sometimes aid greatly in con- 
verting a moist eczema into a squamous one. During the 
day a cure will be hastened by having the ear covered 
with a linen bag made in the fashion of an ear-muff. 
Eczema of the auditory canal is sometimes very annoying 



206 DISEASES OF THE SKIN. 

on account of an accumulation of scales, dulling the hear- 
ing. For this condition an ointment of tannin, one 
drachm to the ounce, or a solution of nitrate of silver, 5 
to 20 grains to the ounce, may be applied thoroughly by 
means of absorbent cotton on a probe, the ear being 
properly lighted by means of a head-mirror, and the 
operator having the requisite skill. Otherwise the tannic 
acid ointment, or one of oxide of zinc, or the diachylon 
ointment may be applied on pledgets of lint rolled up to 
fit the orifice. The insufflation of boric acid will some- 
times be better yet. The ear should not be syringed out 
often, and when it is necessary to do so a solution of borax 
or soda should be used. 

Eczema Barbae is scarcely ever confined to the bearded 
portion of the face, but it generally runs over on to the 
bordering skin, and is often but a part of eczema of the 
face. It has practically the same symptoms as has eczema 
capitis. It needs to be diagnosticated from ringworm and 
sycosis, which see. In treatment, shaving, or cutting the 
hair close, which is better, should be practised so that 
remedies may be closely applied. Plucking the hair from 
the pustules is to be recommended. Its further treatment 
is the same as that of Eczema capitis. It is an obstinate 
form of eczema, prone to relapses. 

Eczema Capitis. The scalp is very commonly the 
seat of eczema, either by itself or in connection with 
eczema elsewhere. It has received various names, such 
as crusta lactea ; porrigo ; melitagra ; scalled head ; milk 
crust ; or vesicular or running scall. While any vari- 
ety of eczema may occur on the scalp, the vesicular is 
very rarely seen, and the most common is the pustular, 
and the final stage, the squamous. In the acute stage 
the scalp may be swollen and boggy, and moist, with the 
hair stuck together. Usually we find the scalp crusted 
with a yellowish serous crust, but more commonly with a 
greenish or blackish purulent crust, while the scalp is 
swollen but little. In some cases of pustular eczema 
there will be discrete, rather large pustules scattered 



REGIONAL ECZEMA. 207 

through the hair, besides moist and crusted patches. 
The hair is always matted together, and the odor from 
the scalp is unpleasant. If the crusts are removed, they 
will soon reform. 

In both the erythematous and squamous forms the scalp 
is red and scaly. In the latter variety there is apt to be 
more or less thickening of the scalp, and in very severe 
cases the scalp may be cracked. Not infrequently there 
will be squamous patches in some places and moist and 
crusted patches in other places. 

With eczema of the scalp there is almost always eczema 
behind the ears. The cervical glands are very often swol- 
len, especially in children, but they need give no anxiety, 
as they very rarely suppurate. In the chronic form there 
may be loss of hair, especially in children, when it is 
sometimes mechanically rubbed off from the occiput. It 
is never permanently lost. All forms are itchy, the 
pustular form least so. The patient may complain of a 
"drawn" feeling of the scalp. As in all inflammatory 
diseases of the scalp there is over-activity of the seba- 
ceous glands, and the crusts will contain a certain 
amount of fat. In chronic cases there may be, on the 
other hand, a deficiency of fat. Pediculi are often found 
on the hair. The disease may affect the whole scalp or 
only a portion of it, and may run an acute or chronic 
course. 

Etiology. The exciting causes of eczema capitis are 
all irritants to the scalp. Sometimes it is well-meant but 
badly directed efforts at cleanliness, especially in children. 
Combing with a fine-toothed comb, too vigorous use of 
soap and water, the use of a too stiff brush, are some of 
these. Pediculi are very often the cause — not the pediculi 
themselves, but the scratching to relieve the itching pro- 
duced by them. An eczema of the occiput should always 
suggest their presence, and search then will generally 
reveal the pediculi or their nits upon the hair. Some- 
times remedies used to kill the lice will set up an eczema, 
such as strong mercurial ointments. In most cases eczema 



208 DISEASES OF THE SKIN. 

of the scalp is but a part of a more or less general eczema 
and due to the same causes. 

Diagnosis. The disease must be differentiated from 
pityriasis capitis, ringworm, erysipelas, lupus erythemato- 
sus, a dermatitis, psoriasis, seborrhoea, favus, pediculosis, 
and syphilis. See under these diseases. 

Teeatment. The treatment of eczema capitis is along 
the same lines as is that of the disease in general. On 
the scalp it is always best to use our remedies either in 
vaseline or oil, as preparations of lard make a disagreeable 
mess with the hair. Nor should a thick ointment ever be 
used, excepting perhaps in children before their hair is 
grown, or on bald heads. If there are crusts on the 
scalp, they must be removed before any local treatment is 
used. This may be done best by soaking them with oil 
for twelve or twenty- four hours, and then washing them 
away with soap and water. Plenty of oil must be used, 
and it is well to tie the head up in a towel over night. 
A woman's or half-grown girl's hair should never be cut 
in order to treat the scalp. In applying remedies to the 
scalp, after the acute stage, they should be rubbed in and 
not merely smeared over it. 

In acute eczema equal parts of lime-water and sweet or 
almond oil, with or without two per cent, of salicylic acid, 
forms a good application. 

In subacute and chronic eczema of the scalp, tar, espe- 
cially the oil of cade, is our most reliable remedy. It 
must be remembered that it can be used much earlier on 
the scalp than elsewhere, and most cases will improve 
under it as soon as the acute stage is passed. It may be 
begun in the strength of twenty drops to the ounce of oil, 
and increased to one or two drachms to the ounce. Many 
people object to the odor of the tar. We can substitute 
for it : 

R. Hydrarg. ammon., gr. xx ; 51 

Vaselini, §j ; 100| M. 

Or, 

R . Ac. salicylici, gr. xx-xxx ; 5-61 

01. olivte, 3j ; 100| M. 



REGIONAL ECZEMA. 209 

The oil of cajuput in five to ten per cent, strength may 
be tried. Neither of these is as good as tar. 

If the disease is in a chronic condition, shampooing with 
green soap or its tincture, followed by some oily, not very 
stimulating application, will prove curative. In this con- 
dition it is sometimes best to exhibit the tar in an alco- 
holic solution. Resorcin in three to ten per cent, strength 
may be used cautiously in this way. If the scalp is 
cracked and thickened, great and prompt amelioration will 
be secured by having the patient wear a close-fitting cap 
of rubber. 

Eczema Crurum. Eczema of the legs acquires its pecu- 
liarities from the fact that the circulation of the parts is 
less active than it is in the upper portions of the body, on 
account of the action of gravity upon the returning venous 
blood. It usually is seen as an eczema madidans, though 
any form may be present. Varicose veins, either super- 
ficial or deep, predispose to it. Pigmentation of more or 
less dark-brown color follows or accompanies it, if of any 
chronicity, and occasionally purpuric spots will be scat- 
tered about the chronic patch. As to treatment nothing 
special need be said except that it is always advisable to 
have the legs bandaged snugly from toes to knee, and 
that the best result will be attained when the bandaging 
is done by the doctor or a trained nurse. 

Eczema Genitalium often causes a great deal of discom- 
fort on account of the excessive itching that accompanies 
it. It affects the scrotum most commonly, which in some 
cases will be greatly thickened and feel like leather. The 
skin of the penis also suffers at times as well as the glans. 
In women, both the lesser and the greater lips of the 
vulva, as well as the entrance to the vagina may be 
affected, and show excoriations and thickening. All 
forms of eczema may be encountered in the genital region. 
In chronic eczema of the penis the organ becomes greatly 
enlarged both laterally and longitudinally, on account of 
the thickening of the skin. The disease may be confined 
to the genitals or extend to the thighs, or the anal region. 
14 



210 DISEASES OF THE SKIN. 

The presence of diabetes should always be suspected in a 
case of this kind, and the urine should be examined for 
sugar. Leucorrhoea is a common cause of the disease in 
women. 

Treatment. In the treatment of eczema of the geni- 
tals, apart from that due to general conditions and spe- 
cially to diabetes, it is essential that men should wear a well- 
fitting suspensory bandage, inside of which the dressing 
may be placed. The itching may be greatly relieved in 
all forms by directing the patient to sit over a vessel con- 
taining hot water and to sop the water up on the parts. 
The skin should be mopped dry, the oxide of zinc oint- 
ment, diachylon ointment, or Lassar's paste immediately 
applied, and the suspensory bandage adjusted. Carbolic 
acid, one or two drachms to the ounce of glycerin and 
water, may also be used, lightly dabbed on, for the pur- 
pose of allaying the itching. It should be followed by 
either of the above ointments. For chronic, thickened 
eczema wearing sheet rubber inside of the suspensory 
bandage will give positive and immediate relief, and 
greatly reduce the thickening. After a few days it is 
well to follow it with a tar or resorcin ointment. In 
some cases nothing will do so well as the application of 
the nitrate of silver solution, already given. The spirits 
of nitrous ether may be used as an excipient of this. 
Hardaway speaks highly of rubbing the scrotum with a 
solution of salicylic acid in alcohol, one drachm to the 
ounce, and following this with a boric acid or diachylon 
ointment. 

Women should use a T-banclage instead of a suspensory. 
Otherwise the treatment is the same. In them I have seen 
the nitrate of silver treatment do remarkably well. 

Eczema Intertrigo occurs w r herever folds of skin come 
in contact, and requires that the parts should be kept 
separate and as dry as possible by means of a dusting 
powder, or by placing a piece of old linen or cheese-cloth 
between the apposed folds of skin. For a dusting powder 
we may use either cornstarch alone or with bismuth, or 



REGIONAL ECZEMA. 211 

zinc oxide. Lycopodium is also an excellent powder, but 
the best powder of all is the compound stearate of zinc. 
The disease often resembles an erythema, but inasmuch as 
both diseases are amenable to the same treatment, absolute 
accuracy of diagnosis is not essential. Kaposi has seen 
gangrenous and diphtheritic inflammation begin in an in- 
tertriginous eczema. As a rule, these cases do best with- 
out ointments. This does not apply to eczema intertrigo 
of the crotch. Here it is well to cover the parts with a 
greasy application so as to protect them from the action 
of the urine. A dilute diachylon ointment often answers 
admirably. 

Eczema Labiorum is usually due to a nasal catarrh, and 
can be cured only when the cause is removed. Eczema 
may occur about the mouth in an orbicular manner. 
Many people suffer from chapped lips, especially in 
winter. This is an eczema of the vermilion border. For 
this little can be done except to caution the patient against 
moistening the lips. Greasing the lips every night with 
camphor-ice or the like keeps them in good condition. 
Glycerin agrees well with some skins, and is harmful to 
others. Cracks may be touched with the nitrate of silver 
stick, and the lip painted with compound tincture of ben- 
zoin. 

Eczema Mammarum et MammiUarum. One of the most 
annoying accidents to befall a nursing woman is eczema 
of the nipples. They become excoriated and fissured, the 
cracks sometimes extending to the base of the nipple. 
At times a drop of pus can be squeezed from the bottom 
of the crack. They are exquisitely sensitive, and every 
time the baby takes hold the woman suffers agony. The 
moisture from the child's mouth and the decomposing 
milk left on the nipple aggravate the trouble. Mastitis 
may complicate matters. In the intervals of nursing the 
nipple scabs over. Either one or both nipples may be 
affected. The disease may extend on to the breasts, or 
the breasts may be affected independently of the nipples. 
"Women with pendulous and heavy breasts frequently 



212 DISEASES OF TffE SKIN. 

suffer with a moist eczema in the sulcus beneath them. 
Apart from this nothing special need be said about eczema 
of the breasts. There is one disease of the breasts, called 
Paget's disease of the nipple, which at first very closely 
resembles eczema, and it is a question whether it is car- 
cinomatous all the way through, or an eczema developing 
into a carcinoma. (See Paget's Disease for diagnosis.) 

Treatment. It is often possible to cure eczema of 
the nipples even while the child nurses. Sometimes it 
will be necessary to wean the child. Women dur- 
ing the latter months of pregnancy should handle their 
nipples every day and bathe them with whiskey or alcohol, 
to which may be added 20 or 30 grains of borax to the 
ounce. This will do much to prevent future trouble. The 
suckling having begun, the nipples should be carefully 
washed off and dried with a soft handkerchief after each 
nursing, and dressed with oxide of zinc or diachylon oint- 
ment, should eczema show itself. Of course, the ointment 
should be removed before the infant is put to the breast, 
and this should be done with as little water and as much 
gentleness as possible. If there are cracks, the child 
should nurse through a rubber nipple, and when it lets go 
the nipple should be dried and painted with compound 
tincture of benzoin, or the solution of nitrate of silver, 
already spoken of. It is also advised to touch the cracks 
with the nitrate of silver stick. This is very painful, 
and of little use as long as the infiltration of the nipple 
that causes them continues. The nipples may be washed 
with a borax solution and covered with an ointment of 
borax. It is always advisable to use nothing that is 
poisonous in the dressings. Hardaway recommends the 
following for eczema under the breasts : 

R. Thymol.^ gr. j. 

Pulv. zinci oleat., 5J- M. 

Eczema Manuuin. Eczema of the hands has been called 
" washerwoman's itch," " grocer's itch," "bricklayer's 
itch," and various other itches. It is in many cases a 



REGIONAL ECZEMA. 213 

trade eczema, caused by strong alkaline soaps, or contact 
with sugar, mortar, or other irritant. It may arise inde- 
pendently of any of these trade causes, or it may be part 
of a general eczema. The acute forms, as they occur upon 
the backs of the hands, do not differ from the same on 
other parts of the body, and the same may be said of the 
chronic forms. The palms are seldom primarily affected, 
but secondarily to eczema of the wrists or fingers. The 
epidermis of the palms, as well as that of the palmar sur- 
faces of the fingers, is thicker than that of the other parts 
of the body, excepting the soles of the feet, and so the 
vesicles do not rupture readily, but are seen like little, 
more or less translucent grains under the skin. When 
they rupture, the skin is left more or less ragged and 
worm-eaten. The skin over all the joints is liable to 
crack and form painful fissures. Chronic eczema of the 
palms prevents free movement of them on account of the 
thickening and the painful cracking. The skin is red- 
dened and covered with large adherent scales. Itching 
is intense at times. The whole palm may be affected, or 
the disease may form limited areas, as upon the center of 
the palm, over the thenar eminence, and upon the finger- 
ends. This form of eczema is often difficult of diagnosis 
from the squamous syphilide. The occurrence of the le- 
sions upon one hand alone should rouse suspicion of syph- 
ilis, especially if little or no itching is complained of. 

Treatment. It is one of the most obstinate of ecze- 
mas to treat, when of chronic form, and requires active 
stimulation by means of tar ; salicylic acid ; the soap and 
salve treatment ; rubbing in 5 to 10 per cent, of the oleate 
of mercury ; or painting with caustic potash. The con- 
stant wearing of rubber gloves is excellent for the purpose 
of softening the skin and preparing it for other remedies. 
It is best to buy the canvas-lined gloves, turn them inside 
out, and wear the rubber next the skin. The hands must 
be kept out of water. Where this cannot be done, great 
care must be used in drying them. It is well to have the 
patient dry on two towels or before ,the fire, and then either 



214 DISEASES OF THE SKIN. 

to thrust the hands in a box of cornstarch powder or flour, 
or preferably to apply the proper dressings. Acute eczema 
of the hands is treated the same as an eczema elsewhere. 
Unna teaches that eczema of the hands and fingers is 
always secondary to eczema seborrhoicum capitis. He 
recommends in the disease, as it affects cooks, housemaids, 
and the like, that the hands, on going to bed, should be 
washed with green soap and water when the eczema is of 
squamous form, and with a weaker soap when it is moist. 
Then a paste of 

Oxide of zinc, 40 parts. 

Chalk, 



or one of 



Lead water, [ aa 20 

Linseed oil, 



Oxide of zinc, 
Sulphur, 
Chalk, 
Linseed oil, 
Lime water, 



20 parts. 



is to be well rubbed in. Before using the paste when the 
eczema is moist it should be powdered with flour. The 
paste is covered with the thinnest rubber tissue, such as is 
used for bouquet handles. This will stick well. Cotton 
gloves can be worn at night. In the morning the dressing 
is not to be removed until the worst of the work is done. 
Then it is to be washed off, and a little of the paste applied 
until time for the evening dressing. 

In eczema of the hands of masons, washerwomen, and the 
like an endeavor must be made to thicken the corneous layer 
of the skin by dressing them at night with a paste of 

Resorcin., ) __ in - . 

TT , • ' . . -, y aa 10 parts. 

Ungt. zinci oxid., j l 

Terrse silicea?, 2 " 

and applying oil or vaseline over it. In the morning the 
hands are not to be washed, but anointed with some oil. 



REGIONAL ECZEMA. "lib 

After a time the corneous layer thickens and the old skin 
falls off. 

Eczema Narium is often, if not always, associated with a 
chronic rhinitis. It is very obstinate. Crusts form on the 
inside of the nose, are picked off, re-form, and after a time 
ulcers result from the constant irritation. Sometimes in 
adults the disease locates itself about the hair follicles, and 
is very annoying. It is a not uncommon point of departure 
for recurrent attacks of facial erysipelas. If long continued, 
it gives rise to a thickening of the upper lip. Furuncles 
sometimes complicate matters. 

In the treatment of these cases the first attention must be 
given to the cure of the rhinitis. Then all crusts must be 
removed by soaking with oil. For the eczema we may use : 

R . Glycerole plumbi subacetat. ,\ _ . 

Ungt. aquse rosae, j aa ^' c M. 

as recommended by Hardaway. 

Herzog l recommends the yellow oxide of mercury oint- 
ment, or equal parts of ungt. plumbi and vaseline, spread 
on lint and accurately applied to the diseased part. Unna 
rolls his zinc and red precipitate ointment muslin into a 
pledget and introduces it into the nose. In obstinate 
cases about the hairs, epilation by electrolysis may have 
to be performed. 

Eczema Palpebrarum is usually of an erythematous 
character, and occurs as part of the same disease else- 
where. Eczema of the cilise, also called blepharitis ciliaris, 
is always pustular. The edges of the lids are swollen, 
rounded, and more or less thickly strewn with pustules or 
crusts. The lids stick together on waking in the morning. 
In the squamous form the edges of the lids are merely red 
and scaly. It is almost always symmetrical, occurs usually 
in strmnous subjects, and is due to conjunctivitis. 

Tbeatmext. The lids should be anointed before go- 
ing to sleep, in order to prevent their sticking together. 
I have always found the following ointment, as given by 
iArchivf. Kinderheilk./1887, p. 211. 



216 DISEASES OF THE SKIN. 

my friend, Prof. D. Webster, of the New York Polyclinic, 
most excellent : 

R. Ac. salicylici, gr. x; '8 

Ungt. hydrarg. oxid. rubra, 3J5 §\ 

Ungt. aquae rosse, 5 V J I 30, M. 

An ointment composed of 

R. Hydrarg. oxid. flav., gr. ij-viij. 

Vaselini, gj. M. 

is recommended by Hardaway. Resorcin, 3 grains in cold 
cream, 2J drachms, is editorially commended in the 
Monatshefte f. prakl Dermal, 1888, vii., 1057. "What- 
ever is nsed, we must be sure that any substance entering 
into it is in an impalpable powder, so as to avoid the pos- 
sibility of getting anything gritty into the eye. Epilation 
may be necessary in some cases. Solutions of bichloride 
of mercury (0.05 to 500) are commended, both for the 
conjunctivitis and the eczema dependent upon it. In any 
event, the conjunctivitis must be treated. 

Eczema Pedum. Eczema of the soles of the feet, though 
not so common as that of the palms, presents the same 
symptoms and calls for the same treatment. The great- 
est difficulty will be encountered in dressing the toes pro- 
perly. For this the ointment should be spread upon a 
long and narrow strip of lint, the center of the strip placed 
against the big toe, and the strip wound in and out be- 
tween the toes. A piece of salve muslin may be substi- 
tuted for this with advantage. A piece of rubber sheeting 
cut to fit the sole and bound down with a bandage takes 
the place of the rubber glove. 

Eczema Unguium. Eczema may affect the nail-fold 
alone, and the nail may be scarcely diseased, or the matrix 
and bed may be diseased, when the nail will lose its lustre, 
and become rough, uneven, striated, and atrophied. Only 
one nail may be diseased, or all of them may be. The 
nail may be depressed in the center and turned up at the 
end with an accumulation of scales under its free border. 
Usually eczema of the nails occurs as a part of a general 



REGIONAL ECZEMA. 217 

eczema, but it may occur as an independent disease. The 
fleshy parts about the nails usually present signs of in- 
flammation, and often of an evident eczema. 

It is best treated by means of cots made of rubber. It 
must be remembered that an ointment can never be used 
when rubber is, as it rots it. If the time has come for an 
ointment, linen or leather cots must be substituted for the 
rubber ones. The ointment to be used will depend upon 
the condition of the skin about the nails. Strapping the 
nails with a 10 per cent, salicylic acid plaster is often 
most satisfactory. 

Universal Eczema is uncommon, and when it does occur 
it is usually of the erythematous or squamous variety/ 
with a tendency to cracking in the skin creases of the 
joints, exudation, scaling, and itching. These symptoms 
will serve to distinguish it from dermatitis exfoliativa, to 
which it bears a strong resemblance. Constitutional dis- 
turbances, such as fever and chills, loss of appetite, and 
digestive disorders, are not uncommon in these truly piti- 
able cases. Furunculosis is apt to complicate matters. 
The patients are slow in recovering and are apt to be a 
good deal pulled down by the disease. 

Treatment. These patients should be put to bed and 
the underlying cause searched for, and if possible removed. 
They are best treated locally by lotions, oils, or vaseline. 
The ordinary Carron oil, equal parts of linseed oil and 
lime-water ; cotton-seed oil with carbolic acid, 1 part of 
acid to 60 of oil ; or simply smearing the body with 
vaseline and powdering on cornstarch, will each relieve. 
Salicylic acid in oil, 1 in 30, will also allay the discom- 
fort. Alkaline baths, warm, and followed by one of the 
above, after tapping the skin gently dry, will also relieve, 
but the bath should not be used more than once a day. 
Its temperature should be about 98° F. ; it should last 
ten or fifteen minutes. Bulkley recommends anointing 
the skin, before drying it, with — 

R. Acid, carbolici, 9J-5y >' 3—16] 

Glycerite amyli, 51 v ; 100, M. 



218 DISEASES OF THE SKIN. 

applying it freely. The best way of drying the skin is 
to envelop the patient in a warm sheet, and pat the skin 
dry. As the intensity of the eczema lessens, the frequency 
of the baths must be reduced. It will gradually become 
localized in patches. 

Eczema Infantile presents certain peculiarities that war- 
rant its being considered as a special variety of eczema. 
It is very prone to be of the pustular form, following the 
rule that in delicate or debilitated subjects an eruption 
upon the skin is apt to be pustular. While in adults 
eczema of the face is usually erythematous, in infants it is 
.nearly always pustular. In them it is quite common, if 
not the rule, to have several regions affected at once, such 
as the scalp, the face, and the region of the crotch. In 
them, also, we have eczema madidans in these regions. 
While in adults that form of eczema is most frequently 
seen upon the legs, in infants it is quite exceptional there. 
Eczema of the scalp in infants presents itself as a thick 
crust formed of purulent matter, epithelial debris, and 
sebaceous matter. This is called " milk crust." When 
the crust is raised the scalp will be found to be thickened, 
swollen, boggy, and moist, with a purulent secretion. The 
whole scalp may be affected, or only the vertex. With it 
there will nearly always be a moist surface behind the 
ears, even though the face may be comparatively or abso- 
lutely free. The lymphatic glands will be swollen, but 
they seldom suppurate. When the face is affected it will 
sometimes be studded over with holes, superficial ulcera- 
tions, which, however, never leave scars. This appearance 
is seen very rarely in adults. It is often striking to note 
that the skin about the mouth and nose, and below the 
eyes, is in perfect health, though pale, while all the rest 
of the face may be involved in the most intense inflamma- 
tion. The creases of the neck, the flexures of the joints, 
and the region of the genitals usually show an erythematous 
or a moist intertriginous eczema. At times the whole 
body will be affected with a general, but very rarely with 



ECZEMA INFANTILE. 219 

an universal eczema. While the pustular and intertriginous 
forms of eczema are the most common, we may have all 
forms present at one time. The papular form is also fre- 
quently met with alone. Itching is usually severe, keep- 
ing the little patient awake at night, and the tearing made 
by the nails to relieve the itching gives rise to immense 
excoriations, especially of the face. Unrelieved the little 
patients sometimes become pitiable objects on account of 
loss of sleep and constant nervous excitement. 

Etiology. There are several causes tending to pro- 
duce eczema in infants. Their skin is vulnerable to all 
irritants. When we consider that the child is born into 
the cold world suddenly, and launched there out of a 
warm atmosphere, in which it was surrounded by an alka- 
line fluid, covered over with a fatty coating, and safe from 
the action of the atmospheric air, we can but wonder that 
its skin escapes as well as it does. More than one-third 
of the cases of eczema occurring before the fifth year of 
life occur in the first year. Add to the vulnerability of 
the skin the overzealous care commonly bestowed upon it 
for a few months after birth, and Ave have a good expla- 
nation for its frequence. Bad diet has much to do with 
its production. The vast majority of the little sufferers 
are nursed too often if at the breast, " every time they 
cry " being the rule ; or fed too frequently or improperly, 
" everything that is going " being again the rule. Inat- 
tention to the condition of the diapers is another active 
cause of the eczema about the genitals. Teething is, 
without doubt, an exciting cause, a fresh outbreak of 
eczema marking the eruption of a new tooth. Want of 
self-control in scratching is an aggravating circumstance. 
The frequent disturbances of digestion, so common at this 
period of life, predispose the infant's skin to eczema with 
rather more force than do the same troubles in adults. 
Fat babies are frequent subjects of eczema, especially of 
the intertriginous variety. 

Treatment. The treatment of eczema infantile is 
along the same lines as that of eczema in adults. Special 



220 DISEASES OF THE SKIN. 

stress must be laid upon the feeding of infants, and strict 
rules must be laid down for the parent's guidance. The 
condition of the breast milk must be inquired into, as it 
is often of too poor quality to nourish the child. Women 
will sometimes nurse their children far too long, with the 
idea of preventing conception. If the child is bottle- 
fed, the quality of the milk must be investigated, and 
it as well as the amount regulated. It is also very neces- 
sary to insist upon the child wearing a mask in eczema of 
the face and scalp. This may be made of light flannel or 
linen, a piece of the stuff being cut somewhat after the 
shape of the face, with holes cut out for the nose, eyes, 
and mouth. A skullcap is to be made, onto which the 
mask may be sewed, or pinned with safety-pins. The 
ointment is to be spread upon lint or cheese-cloth — a strip 
for the forehead, one for the chin, and one for each cheek. 
These are to be laid upon the face, and then the mask put 
over them, fastened to the skullcap, and tied behind the 
head by two strings from its lower corners. It is aston- 
ishing what relief this affords to the itching, and how 
much more rapidly the case improves under it. As it is 
impracticable to use the mask in public practice Unna's 
paste made of 



R • Oxide of zinc, 40 parts. . 

Chalk, ) 

Lead water, V aa 20 " M. 

Linseed oil, j 



may be used as a substitute. In making, the first two in- 
gredients are to be mixed together, and then the last two, 
and then the two parts thus formed. It is to be painted 
on the part and cannot be readily rubbed off, though it 
can be washed off with a little oil. 

The itching of the skin may be relieved by appropriate 
dressings, but if not it may become necessary to put the 
child in a home-made straight-jacket, by putting it in a 
pillow-case and sewing up the same between the arms and 
body. This is an extreme measure and should not be 
lightly adopted. In eczema of the crotch great care 



ECZEMA SEBORRHOICUM. 221 

must be given to changing the napkins as soon as soiled. 
Fresh, clean ones must be put on, not those that have 
been dried without being washed. Dr. George H. Fox 
has called attention to a tight prepuce as the cause of 
eczema in male children. The urine dribbles away, so 
that a few drops wet the cleau diapers, and thus keep up 
the trouble. In such cases judicious stretching of the pre- 
puce may obviate the necessity for circumcision. Water 
must be kept from the skin in all acute cases. 

Internally, calomel in tablet triturates, one-tenth grain, 
three times a day for three days will give us good aid in 
many cases, even though the bowels are not constipated. 
After an interval of three days the calomel is to be given 
again. Care must be taken not to produce too frequent 
and loose movements of the bowels. Other medication 
will be necessary according to the nature of the case. 
Cod-liver oil will often cure a case which has been very 
obstinate. The local treatment is according to the rules 
already given under Eczema. 

Eczema Marginatum. See Trichophytosis. 

Eczema Seborrhoicum. Unna published his first paper 
on this subject in 1887. He does not believe that there 
is such a disease as seborrhcea sicca or pityriasis, but that 
both of these, as well as several other recognized forms of 
eczema, are all forms of his seborrhoeal eczema. Among 
several other articles on the subject that of Dr. George T. 
Elliot in Morrow's System of Genito-urinary and Skin Dis- 
eases, Vol. III., stands easily first. It is upon the papers 
of Unna and Elliot that this section is founded. The 
latter proposed the name of dermatitis seborrheica for the 
disease, which is the preferable title. 

Symptoms. Unna teaches that the starting-point of 
almost all cases of seborrhoeal eczema is the scalp ; more 
rarely the margin of the eyelids, the axillae, bend of the 
elbows, or cruro-scrotal fold. Upon the head it exists 
mostly as an affection that is scarcely noticeable at its on- 
set, and it is only after months or years that a sudden in- 



222 DISEASES OF THE SKIN. 

crease, loss of hair, an unusual amount of scaliness or col- 
lection of crusts, severe itching, or, finally, a circumscribed 
moist spot, or an evident eczema, leads the patient to con- 
sult a physician. The hair during the early stage is ab- 
normally dry. A progressive alopecia pityrodes may show 
itself, the scaliness decreasing with the loss of the hair to 
make way for a hyperidrosis oleosa. Or the scaling and 
crusting may increase, a corona seborrhoica may form 
along the hair line, and the affection may extend upon the 
temples, over the ears to the neck, or on to the nose and 
cheeks. Or the catarrhal symptoms may be pronounced, 
and a moist eczema affect the scalp and ears, and, in chil- 
dren, the cheeks and forehead. (It will be readily recog- 
nized that his slightest form is the usually recognized pit- 
yriasis, his more pronounced form is seborrhoea sicca, and 
his most pronounced form is the seborrhoea Avith dermatitis.) 

Next to the head, the sternum is a favorite site for the 
eruption, where it most commonly assumes the crusted 
form, and most rarely the moist form. The sternum is 
affected secondarily to the scalp. The crusted form is in 
round or oval spots the size of the finger-nail ; these group 
and partly coalesce, forming patches the size of a silver 
half-dollar, having a scalloped border. The color is yel- 
low, with a delicate red border. These may clear up 
somewhat in the center and form circles, or break and 
form bow-shaped figures with the convexity outward. 
The lesions of this form are usually covered with a greasy 
crust. The back is similarly affected. (This is Duhr- 
ing's seborrhoea corporis.) 

In the axillae we meet most commonly with the moist 
form, and here it shows a tendency to spread with rapid- 
ity upon the thorax. From the shoulders it spreads clown 
upon the arms almost always in the form of yellowish-red, 
crusted papules, which tend to unite in patches, and also 
to form rings. At times it may look very much like pso- 
riasis. It shows a predilection for the flexor surfaces. 
The backs of the hands and fingers are often affected with 
a moist eczema, the trunk and arms escaping. 



ECZEMA SEBORRHOICUM. 223 

Upon the palms and soles we find little heaped-up masses 
of scales corresponding to individual coiled glands and re- 
sembling psoriasis guttata. Later the epidermis peels off, 
bnt there is never any moisture. The crusted form gener- 
ally appears in ring or serpiginous patches on the trunk, 
buttocks, and hips. The cruro-scrotal fold and the ap- 
proximating surfaces of the thigh and scrotum are favorite 
locations for the disease, probably forming here many of 
the so-called cases of eczema marginatum in its dry form 
with festooned margins to the patches, or as an intertrigo 
when it is more moist. The thigh and extensor surface 
of the knee are but little affected, while the popliteal space 
and the leg often are, either in the large papular or the 
thick-crusted form. 

Upon the bearded portion of the face, when the beard is 
worn, we find either a diffused pityriasis, or circumscribed, 
reddened, itchy patches. Upon the face of women and the 
unbearded portions of the face in men we have circum- 
scribed, scaly, yellowish or yellowish-gray, slightly ele- 
vated patches, mostly on the forehead, cheeks, and naso- 
labial fold. There may also be red papules, free from 
scales or with fine yellow ones, with redness of the skin 
between the papules. The face is the favorite location 
for a moist seborrhoeal eczema, in children especially. 
The eyebrows are often involved as well as the eyelids. 
The latter are often swollen, and red, and scaly. The 
vermilion borders of the lips may be affected and the lips 
swell, scale, crust, and perhaps crack. The disease may 
attack both the outer parts of the ear and the external 
auditory canal. Scaliness, itching, and great increase of 
cerumen mark the process in the latter situation. 

Etiology. Seborrhoeal eczema occurs at all ages and 
in both sexes, but it is specially prevalent between puberty 
and thirty years of age. Though most of the patients 
with it seem to be in good health, careful inquiry will 
bring out the fact that they either are not in perfect con- 
dition or they are living unhygienic lives. Elliot thinks 
that an indoor life favors the disease. Contagion probably 



224 DISEASES OF THE SKIN. 

plays a considerable part in causation, and barber sliops 
doubtless are distributing centers of the malady. It is 
quite impossible to estimate the prevalence of the disease, 
as only the more pronounced cases are seen by the phy- 
sician. 

Pathology. According to Elliot, it is a dermatitis of 
catarrhal nature. He found evidences of inflammatory 
infiltration about the papillary vessels, and the ascending 
branches from the subpapillary plexus, and along the hair 
follicle, even in what is usually regarded as a pityriasis. 
In seborrhoea sicca, so called, the infiltration extended to 
the plexus itself, while in the higher grades the inflam- 
mation involved nearly the entire cutis. The sebaceous 
glands were apparently unchanged, and there were no 
evidences of the incomplete metamorphosis of their cells, 
such as is usually described in seborrhoea sicca. Con- 
trary to Unna's observations, he never found any fat in 
the sweat glands or their ducts, but there were evidences 
of degeneration of the glands ; nor did he find fatty in- 
filtration of the cutis or rete. 

Unna has described a mulberry coccus in this disease. 
Dr. Merrill l has succeeded in isolating a diplococcus, in 
making a pure culture of it, and in reproducing the dis- 
ease by inoculation. If his observations are corroborated, 
we have the evidence that the disease is parasitic. 

Diagnosis. Many of our cases of eczema are included 
by Unna and Elliot in seborrhoeal eczema or dermatitis, 
as the latter thinks the preferable name. In diagnosis 
stress is laid upon the fact that the disease begins upon 
the scalp and spreads from there downward in a more or 
less capricious manner ; upon the more or less absence of 
itching ; upon the superficial character of the lesions, 
their tendency to take on definite forms, their yellowish 
color, and the greasy feeling of the crusts. In all these 
things the disease differs from an eczema. At times 
seborrhoeal eczema of the body bears so striking a like- 
ness to pityriasis rosea that it is hard to differentiate the 
'N. Y. Med. Journ., 1895, lxii., 528 and 1897, lxv., 322. 



ECZEMA SEBORRHOICUM. 225 

two. The rings of pityriasis rosea are not so greasy and 
yellow, and have fawn -colored, dry centers. Then pity- 
riasis rosea rims a rapid and self-limited course, whereas 
seborrheal eczema is chronic. If pityriasis rosea occurs 
typically upon the trunk, there is no difficulty ; but when 
scaly ring-shaped patches occur on the limbs alone a posi- 
tive diagnosis cannot be made without a good deal of 
study. 

The psoriasiform seborrheal eczema differs from psoria- 
sis in occurring in locations not typical of psoriasis, and 
in having a more yellowish cast of color, and more greasy, 
yellowish scales. Many cases can be diagnosticated only 
by taking into consideration the probabilities for and 
against psoriasis. 

Teeatment. The best remedy for the moist form is, 
according to Unna, sulphur, and for the scaly and crusted 
forms chrysarobin, pyrogallol, and resorcin. It is always 
necessary to direct special attention to the scalp and eye- 
lids, as these are the foci from which the disease spreads. 
For the disease upon the back of the hand, it is recom- 
mended that the affected parts be covered with a thin 
layer of lint soaked in the following solution diluted one- 
half: 

R. Eesorcin, \ -- 10 

Glycerin, / aa iU paits " 

Alcohol, dil., 180 " M. 

and over this a large piece of gutta-percha tissue is to be 
bound. This is to be used at night, and during the day 
it is to be kept dressed with a zinc-oxide paste with or 
without tar, sulphur, or resorcin. 

In my hands sulphur in some form answers best in 
most of the cases. Elliot commends for the disease, 
specially as it affects the scalp, lotions of resorcin, 3 to 10 
per cent, in equal parts of alcohol and water, with which 
the parts are to be moistened several times a clay. The 
scalp is to be washed with soap and warm water once or 
twice a week. If the lotion is too drying, a resorcin oint- 
15 



226 



DISEASES OF THE SKIN. 



ment of the same strength is to be used once or twice a 
week or on alternate days. He uses sulphur as an after- 
treatment. 

Elephantiasis (E 2 l-e 2 -fa 2 nt-i 2 -a'-si 2 s). Synonyms : Bar- 
badoes leg ; Cochin-China leg ; Glandular disease of Barba- 
does ; Sarcocele of the Egyptians ; Tropical big-leg ; Buc- 
nemia tropica ; Morbus elephas ; Pachydermia ; Spargosis ; 
Phlegmasia Malabarica; Hernia carnosa; Elephantiasis 
Indica seu Arabum. 

Fig. 21. 




Elephantiasis. (After Taylor.) 



A chronic endemic or sporadic disease of the skin, char- 
acterized by hyperplasia of the skin and subcutaneous tis- 
sues, due to a stoppage of the lymphatics, affecting chiefly 



ELEPHANTIASIS. 227 

the lower extremities, and marked by enormous enlarge- 
ment of the affected part. 

Symptoms. In certain tropical regions, such as India, 
China, Japan, Egypt, Arabia, the West Indies, and South 
America, the disease is endemic, but sporadic cases occur 
in all parts of the world. The symptoms of the two forms 
differ only in that in the endemic variety there is usually 
what is called "elephantoid fever," with lumbar pain, 
nausea, and vomiting, and followed by sweating. The 
fever is of high grade, and bears a striking resemblance 
to malarial pyrexia. In sporadic cases the characteristic 
fever is wanting, though usually there is some constitu- 
tional disturbance preceding the local symptoms. In 
other instances the fever is altogether wanting. 

Locally the affected part at first is attacked apparently 
by erysipelas, or a deep dermatitis, phlebitis, or lymphan- 
gitis ; it becomes greatly reddened and swollen ; and there 
may or may not be a clear or milky discharge from the 
skin, and an eruption of vesicles. After a time these 
symptoms subside, but the part does not return to its 
normal size, and there is some pitting of the skin on 
pressure. After a few months there is a repetition of the 
attack, and the part is left still more enlarged. And so 
the case progresses with varying periods of quiescence, 
and recurrent erysipelatous attacks, each one leaving the 
part more thickened than before, until it attains enormous 
proportions. The normal contour of the part is lost ; the 
folds of the skin are obliterated, the surface is smooth 
and shiny, and the color grows darker, even blackish. 
Now no impression can be made upon the swelling by 
pressure of the finger. Ulcerations are apt to occur, 
and some cases show varicose lymphatics which are 
tender and painful, and may rupture of themselves or 
by accident and discharge a clear or milky chylous, coag- 
ulable fluid. The escape of this fluid saps the patient's 
strength. 

The parts most frequently affected are the legs, usually 
one, but may be both ; and next to them, the male or 



228 DISEASES OF THE SKIN. 

female genitals. It occurs also on the arms, face, ears, 
female breast, and tongue. When the leg is the seat of 
the disease it becomes so large as to interfere with loco- 
motion and compel the sufferer to take to his bed. The 
surface of the limb may be smooth ; or uneven on account 
of the varicose l) T mphatics ; or warty on account of en- 
largement of the papillae. The foot and leg may melt 
into each other, as it were, all trace of an ankle being lost. 
Wherever there are two surfaces in contact there is apt to 
be a decomposition of the sweat, sebaceous matter, and 
epithelium, giving rise to a foul odor, like, but worse than, 
that of an ordinary intertrigo. The lymphatic glands in 
the groin are enlarged. Eczema may develop with its 
attendant itching. The appearance of this elephantine 
leg gave the name to the disease. When the scrotum is 
the affected part, vomiting often occurs in the febrile at- 
tacks, as Avell as pain in the groins, along the spermatic 
cord, and in the testicles. Hydrocele may develop, and 
the abdominal rings, overstretched by the swollen cords, 
may give opportunity to the formation of hernia upon the 
subsidence of the acute symptoms. The scrotum may 
become so large as to reach the ground when the patient 
is standing, and one case has been reported in which it 
weighed one hundred and ten pounds. One form of the 
affection is called " lymph scrotum or nsevoid elephanti- 
asis," on account of the marked dilatation of the lym- 
phatics. 

There are all degrees of thickening of the skin and 
subcutaneous tissues, but the recurrent attacks of erysipe- 
las and the progressive enlargement are characteristic of 
all. The bones may become enlarged. This is a very 
rare affection, which is called "acromegalia." In the 
Lancet of June 11th, 1887, several cases are reported, one 
of which was on exhibition in a travelling show as the 
" Elephant man." In his case the head attained massive 
proportions. 

Etiology. The disease occurs in both sexes and in 
all ages, but is most common in men of middle life and in 



ELEPHANTIASIS. 229 

the dark-skinned races. Moncorvo l reports a case in an 
infant four months old, and speaks of a case in one fif- 
teen days old. He believes that it may develop in utero. 
Floras 2 reports a case beginning at birth and remaining 
stationary for fifteen years, when it assumed the typical 
course of the disease. It is particularly prevalent in 
damp, malarious parts of the seacoast. It is not sup- 
posed to be hereditary, though in countries in which it is 
endemic several members of the same family may be af- 
fected by it. Leprosy and elephantiasis have been acci- 
dentally associated. Exposure to cold, phlegmasia dolens, 
cellulitis, ulcers, lupus, repeated attacks of eczema or ery- 
sipelas, posture, as the hanging down of a limb on account 
of rheumatism, may give rise to the disease. In fact, any 
disease of the skin that is attended by repeated inflam- 
matory outbreaks favors the occurrence of elephantiasis. 
The filaria sanguinis hominis is said to be the cause of 
the endemic form of the disease. It is not found in 
every case, and is rarely encountered in sporadic cases. 

Pathology. Anything that will occlude the lymphatic 
channels may cause the disease. In endemic cases it is the 
ova of the filaria that do this. In sporadic cases the sev- 
eral etiological factors play the same part. However 
caused, the result is an enormous hypertrophy of the sub- 
cutaneous tissue from increase of fibrous tissue in various 
stages of development. The corium is also increased in 
thickness and there is proliferation of the epidermis, en- 
largement of blood vessels, lymphatics, and nerves. In 
advanced cases the muscles undergo fibro-fatty changes, 
and the bones become enlarged (Crocker). 

Diagnosis. The recognition of elephantiasis is easy, as 
its symptoms are pronounced. In some cases of syphilis, 
however, an elephantiasic thickening of the foot or feet 
takes place that may be thought to be elephantiasis. In 
it, however, there is an absence of the history of repeated 
inflammatory attacks, the outline of the thickening is rather 

'Eev. mens, des Mai. de l'Enfance, 1886, iv., 101. 
2 Archiv klin. Chirargie, 1888, xxxvii., 598. 



230 DISEASES OF THE SKIN. 

well defined, and old cicatrices or ulcers characteristic of 
syphilis will commonly be found. The condition is one of 
gummatous infiltration with chronic oedema, consequent 
upon obstruction of the lymphatics. 

Treatment. The best thing for a patient with en- 
demic elephantiasis to do is to go to a more healthful 
climate. The treatment of the patient during the exacerba- 
tions is purely symptomatic, with fomentations, quinine, 
iron, and the like. Various measures for the cure of the 
disease have been proposed, but none is perfectly satis- 
factory. Of course, the scrotal tumor may be cut off. 
The leg has been amputated at the hip, a dangerous opera- 
tion. Unfortunately the other leg has become diseased 
soon after the one has been cut off. Ligature of the 
femoral artery has been performed, but the result has not 
been satisfactory. Compression by means of a Martin's 
rubber bandage, or the ordinary roller bandage, will afford 
relief. When it is left off for a time enlargement will 
again take place. It, of course, cannot be used while in- 
flammation is present. Bentley 1 has reported the cure of 
a case by the inunction of a half-drachm of mercurial oint- 
ment twice daily, and the application of a firm bandage 
for fourteen days. After that the inunctions were made 
once a day. Internally he gave iodide of potash alone, or 
in this formula : 



M. 



Galvanism has produced alleviation, if not cure, in 
some cases. Hardaway has seen great amelioration in 
one case by the use of Squire's glycerole of the subacetate 
of lead. Massage is beneficial. Stretching or excision 
of a part of the sciatic nerve is spoken of by J. Nevins 

'85. 



R. Potass, iodid., 


9ij; 


li 


Potass, chlor., 


5J; 


15 


Sol. hydrarg. perchlor., 


Sss; 


615 


Inf. chiretta, 


ad gvnj ; 


ioo| 


Sig. §ss three times a day. 







EPIDERMOLYSIS. 231 

Hyde as having been followed by amelioration of the con- 
dition. 

Prognosis. Unless exhausted by the loss of lymph 
the disease may last indefinitely without deterioration of 
the health. Death may result from pyaemia or throm- 
bosis. The patient often dies from some intercurrent af- 
fection. 

Elephantiasis Grecorum. See Leprosy. 

Emphysema of the skin is a rare accident. It usually 
affects the upper chest and neck, and is due to a rupture 
of the pulmonary alveoli on account of vomiting or par- 
oxysmal coughing, and the air making its way under the 
skin. The affected part looks swollen, feels cushiony, and 
gives a delicate crackling sound on palpation. There will 
be a history of the sudden occurrence of the swelling after 
coughing or vomiting, and probably more or less dyspnoea 
will be experienced. The air slowly escapes, and the 
parts return to their normal condition. 

Endemic Verrugas. See Favus. 

Endurcissement du Tissu Cellulaire. See Sclerema 
neonatorum. 

Engehires. See Dermatitis calorica. 

Ephelides. See Lentigo. 

Ephidrosis. See Hyperidrosis. 

Ephidrosis Omenta. See Haematidrosis. 

Ephidrosis Tincta. See Chromidrosis. 

Epidemic Skin Disease of Savill. See Dermatitis Epi- 
demica. 

Epidermolysis (E 2 p-i 2 -du 5 rm-o 2 l r -i 2 -si 2 s). Synonyms : 
Acantholysis bullosa (Goldscheider and Joseph) ; Derma- 
titis bullosa (Valentine). This is a rare disease, or rather 
peculiarity of the skin, in which bullae arise upon the 
slightest pressure. The disease shows itself in infancy, 
and occurs especially upon the hands and feet, but may 






232 DISEASES OF THE SKIN. 

occur anywhere on the body. The tendency to the for- 
mation of bullae lessens toward middle life. The lesions 
begin either as a red spot, which is itchy, or without pre- 
cedent redness or other subjective symptoms. The bulla 
begins to form shortly after the exciting pressure has been 
received, and keeps on enlarging for two or three days. 
It then gradually decreases, dries into a crust, which falls, 
leaving healthy skin. If the bulla is broken, it discharges 
a yellow, slightly sticky fluid, and leaves a suppurating 
base. The disease is hereditary in certain families, but it 
may occur independently of this. It is most pronounced 
in summer-time. In most cases hyperidrosis is pro- 
nounced. Elliot, 1 from his microscopical study of the 
disease, believes it to be " due in a predisposed individual 
to an excessive response on the part of the blood vessels to 
an external irritation, and the consequent pouring out of 
an enormous amount of serous exudation/' He regards 
it as " an inflammatory process, originating in the cutis 
itself, and manifesting itself by the formation of bullae 
after slight or severe traumatisms." 

Epithelialkrebs. See Epithelioma. 

Epitheliom Kystique Benin. See Adenoma of sweat 
glands. 

Epithelioma (E 2 p-i 2 -thel-i 2 -o / -ma 3 ). Synonyms : (Fr.) 
Epitheliome cancroide ; (Ger.) Epithelialkrebs ; Can- 
croid, Skin cancer, Epithelial cancer, Noli me tangere. 

Epithelioma is a chronic, progressive, malignant new 
growth in the skin or mucous membrane, which is char- 
acterized by the formation of ulcers with raised, hard, 
waxy edges, and by a strong tendency to return after ap- 
parent removal by knife or caustic. 

Symptoms. Epithelioma always begins in a most in- 
nocent manner, and may be present for months or years 
before the patient dreams that he has a serious disease. It 
may occur upon the skin alone, or upon the mucous mem- 

1 Jour. Cutan. and Gen-Urin. Dis., 1895, xiii. ; p. 10. 



EPITHELIOMA. 



233 



brane alone, or upon both the skin and mucous membrane 
at their line of juncture. Epitheliomas occurring upon 
the tongue, larynx, or uterus do not concern us here, as 
they belong to the domain of surgery. The starting- 
point of the disease may be a crack or an abraded scaly 
spot, as on the lip ; a small, flat, scaly sebaceous patch ; 
a white, pearly looking, hard nodule ; a senile or other 
wart or papilloma ; a pigmentary mole ; a cicatrix ; an 
adenoma ; a chronic or lupous ulcer ; a psoriatic patch, 
or some other new growth in the skin. Some of these 



Fig. 




Epithelioma. 
(From. Prof. G. H. Fox's service at the Vanderbilt clinic.) 



lesions may have been present for many years, as for in- 
stance, a mole. Some appear but a short time before they 
frankly declare their nature, such as the waxy nodule. 
However it may begin, after a varying time ulceration 
occurs, the disease spreads at its edges, and the ulceration 
grows deeper and deeper, eating its way through skin, 
muscles, and bone in the infiltrating form, or creeping 
over the surface in the most superficial form. The lym- 
phatic glands may be involved early in the course of the 
disease, or not for many years. Eventually they become 
swollen, hard, break down, and ulcerate, assuming the ap- 
pearance of an epitheliomatous ulcer. A typical epithe- 
liomatous ulcer is irregular in shape, with raised, hard, 



231 DISEASES OF THE SKIN. 

waxy-looking, rounded, or everted edges, over^which, 
quite commonly, course dilated blood vessels ; the floor is 
uneven, bleeds easily when touched, and is covered by a 
brownish crust, or a sanious, purulent secretion. Epithe- 
liomas are usually single lesions, but they may be multi- 
ple. Some years ago there was a patient in Dr. George 
H. Fox's service at the New York Skin and Cancer Hos- 
pital who had scores of epitheliomas developing from 
large, waxy, reddish nodules scattered all over his face. 
Sometimes a single epithelioma attains vast dimensions, 
involving the whole of one side of the face, scalp, and 
neck in one huge excavated ulcer. Sometimes before the 
characteristic ulceration develops the new growth may 
take the form of a single enlarged papilla, or a group of 
them. In some cases it may have a cauliflower-like ap- 
pearance, spreading out from a more or less narrow base. 
Fissures are apt to form between the papillae, and then 
there is usually an offensive discharge. This is called the 
papillary form. The most typical case of the cauliflower- 
form that I have seen was on the vulva. 

Subjective symptoms are absent in many cases at first, 
but in the deep, infiltrating form pain of a lancinating 
character is present. This often is so severe that the suf- 
ferer is robbed of his sleep. Sometimes there is no pain, 
and the patient experiences only the discomfort incident 
to the ulceration. Sooner or later in nearly all cases 
lancinating pain is a symptom of the disease. 

The course of the disease is always chronic. Different 
cases show different degrees of malignancy. Some will 
prove fatal in four years or less ; some will last indefi- 
nitely. There is no tendency to recovery, though at 
times a partial attempt at healing will be made. I have 
watched one superficial epithelioma in an old Irish woman, 
in Prof. E. B. Bronson's service at the New York Poly- 
clinic, creep over the skin of the face, healing up in the 
older parts while spreading ahead. She refused active 
interference. While all epitheliomas show a strong tend- 
ency to return after operation and in the scar left by 



EPITHELIOMA. 235 

it, in some cases this tendency is much more marked than 
in others. 

While epithelioma may occur upon any part of the 
body, it is more frequently located upon the lower lip, 
where it occurs, according to Paget, in 50 per cent, of the 
cases. The next most common location is the face. The 
external genital organs of both sexes, and the anal region 
more rarely, are other common sites. The upper lip is 
very rarely affected. A favorite location upon the face is 
upon the side of the nose and near the inner can thus of 
the eye. Here it is very apt to pass over onto the eye- 
lid, and destroy it. Not infrequently it begins upon the 
eyelid itself. 

It is customary to describe a number of forms of epi- 
thelioma, but it seems to me much better, especially for a 
student, not to encumber his mind with too many names. 
The superficial, deep-seated or infiltrated, and the papil- 
lary forms have already been mentioned. The chimney- 
sweep's cancer is an epithelioma of the scrotum, met with 
in paraffin-workers and chimney-sweeps. The rodent ul- 
cer used to be described as a special form of disease, but 
it is now considered to be an epithelioma. Clinically, it 
is supposed to be characterized by occurring on the skin 
of the upper half of the face, by running a slow and pain- 
less course, by not involving the lymphatics, and by per- 
pendicular rather than lateral extension. 

Etiology. The cause of epithelioma is often obscure. 
We know that repeated irritation of a part is often fol- 
lowed by its advent. Smoking short clay pipes is not 
uncommonly folloAved by epithelioma of the lip ; a ragged 
tooth accounts for many an epithelioma of the tongue ; 
the wearing of spectacles or eye-glasses has in some cases 
apparently caused the new growth upon the nose ; con- 
stant picking or inadequate attempts at the removal of 
warts and scaly spots would seem to account for epitheli- 
oma of the face ; and the scratching to relieve the pruritus 
of the anus may play the same part in producing the dis- 
ease about the anus. This constant irritation would ex- 



236 DISEASES OF THE SKIN. 

plain the appearance of epithelioma in paraffin-workers 
and chimney-sweeps, in chronic ulcers, psoriasis, old cica- 
trices, and the like. A congenital or acquired phimosis 
and the repeated inflammation due to decomposing smegma 
are the forerunners of the disease upon the penis. Age is 
the most pronounced predisposing cause. The disease is 
rare under thirty years of age, and increases in frequency 
beyond that period. Heredity has some influence, though 
D. Lewis has found that it is not so well marked as it is 
frequently assumed to be. Males are more often affected 
than females. It seems to have a predilection for all 
neoplastic growths. The theory of Darier and Wickham 
is that it is parasitic and due to psorosperms. This is 
still unproved. It is surmised by some that it is con- 
tagious. It is true that there is some evidence both of 
this and its endemic nature. 

Pathology. Crocker sums up the pathology of the 
affection as follows : " The essence of the epitheliomatous 
process is the development of epithelium and its infiltra- 
tion into the deeper tissues where it does not normally 
exist, and where its presence produces irritation and con- 
sequent inflammatory changes." " Cell-nests, consisting 
of horny transformed cells in the center, and of lamina? of 
flattened epithelium externally, are characteristic of the 
disease, but are not present in every case, nor is their 
presence always necessary for a diagnosis." (Robinson.) 

Diagnosis. The disease must be differentiated from 
lupus, syphilis, papilloma, and seborrheal warts. From 
lupus it differs in an entire absence of brownish lupus 
tubercles ; in beginning late in life, as a rule, while lupus 
begins in early life ; by its comparatively more rapid 
course ; its lancinating pain ; the involvement of the lym- 
phatic glands ; the deep ulceration ; the waxy, raised, hard 
margin ; and the development of the cancerous cachexia. 
From syphilis it differs in having a single and not a mul- 
tiple lesion ; in its slower course ; in its showing no tend- 
ency to recovery ; in its not responding to internal treat- 
ment ; in its painfulness ; and in its waxy, raised, hard 



EPITHELIOMA. 237 

margin. An initial lesion of syphilis on the lip has not 
infrequently been taken for an epithelioma. In it we 
have more rapid growth, more induration, an early en- 
largement of the neighboring lymphatic glands of peculiar 
hardness, and the appearance of secondary eruptions on 
the body, all of which are wanting in an epithelioma. 
From papilloma and seborrheal warts there are no positive 
diagnostic marks of distinction. Either of the two diseases 
appearing late in life or showing symptoms of activity at 
that time should rouse our suspicions. 

Treatment. Complete and radical destruction of the 
disease is the only thing to be done in the treatment of 
epithelioma. As a prophylactic measure it is well to de- 
stroy all suspicious warts appearing after middle life, and 
to apply appropriate treatment to seborrhoeal patches oc- 
curring at the same period. Superficial caustics should 
never be used to an epithelioma, as they only encourage 
its growth. The radical treatment will differ with the 
point of view, all surgeons inclining to the knife, while 
dermatologists advocate the curette or powerfully destruc- 
tive caustics. If the knife is used, it must cut out a wide 
margin beyond the growth. Extirpation is especially ap- 
plicable, and the most appropriate treatment of epithelioma 
of the lip, eyelids, and penis. In the latter the organ must 
be amputated above the ulcer, if that has attained any size, 
and the inguinal glands likewise taken out. In all cases 
in which the lymphatic glands have become involved they 
should be taken out. 

To all superficial epitheliomas and to many of the in- 
filtrating variety Schwimmer's plan of treatment will be 
applicable, and will prove curative. The growth is to be 
scraped out thoroughly with the dermal curette (Fig. 23); 
the diseased tissues will give way readily ; the bleeding is 
to be stopped by pressure ; and a pyrogallic acid ointment 
of 33 J per cent, strength is to be applied. Care should be 
taken that it be applied exactly to the growth, for though 
it exerts its greatest action upon the diseased tissues, it 
also acts upon the sound skin. This ointment will pro- 



238 



DISEASES OF THE SKIN. 



duce a black crust over the growth, on account of oxida- 
tion of the acid, and will cause a free discharge from the 
scraped surface during a few days. The discharge be- 
comes less by degrees. After a week or ten days the 
black crust is to be removed by covering it with carbol- 
ized vaseline for twenty-four or forty-eight hours. Last 
of all mercurial plaster is to be applied, under which the 
part will heal. This method gives most satisfactory re- 
sults, and is not particularly painful if cocaine is used hy- 
podermically before the scraping. Smaller epitheliomata 
can be curetted without using cocaine. 

Fig. 23. 




The dermal curette. 



Arsenic holds the first place among caustics. Marsden's 
paste, composed of one or two parts of arsenious acid and 
one part gum acacia, by weight, rubbed together and 
mixed with water into a paste of the consistency of butter 
just before using, is perhaps the most often used. It is 
dreadfully painful and often causes great oedema. It 
should be applied to the affected part on linen, the paste 
overlapping the edge of the tumor by half an inch, and 
left on for twelve to twenty hours, according to the pa- 
tient's endurance. Poultices are to be applied after the 
paste, and kept on continuously till the slough separates, 
and then simple ointment used. If the growth has not 
been destroyed, the process may be repeated. This is the 
treatment recommended by A. R. Robinson. 1 Lewis 2 has 
had good results from using Bougard's paste, as follows : 

1 Atlantic Med. and Surg. Jour., 1895-6, xii., 713. 
2 Journ. Cutan. and Gen.-Urin. Dis., 1890, viii., 70. 



EPITHELIOMA. 239 

aa 60 



R . Wheat flour, \ 
[Starch, J 

Arsenic, 
Cinnabar, 
Sal. ammoniac, 
Corrosive sublimate, 
Solution chloride of zinc © 52°, 245 



50 



M. 



The first six ingredients are separately ground to a fine 
powder and mixed in a mortar. Then the solution of the 
zinc is slowly added while the mass is stirred. It is to 
be kept covered in an earthen jar. A portion is to be ap- 
plied accurately to the part and kept on for thirty hours, 
and followed by a poultice. Cocaine, 20 per cent., may 
be added to decrease the pain. Lactic acid is another 
powerful caustic, to be applied by mixing it with an equal 
part of finely powdered silica and spreading it upon 
gum-paper. It is kept on for twelve hours and renewed 
twenty-four hours afterward. Hardaway prefers to apply 
the syrupy acid by means of absorbent cotton for ten or 
fifteen minutes, and then wash off the excess of acid with 
water. This is done daily. Caustic potash is recom- 
mended by A. R. Robinson for epithelioma of the lip. 

The thermo- and galvano-cautery may also be used. 
Resorcin has its advocates, as has caustic potash, chloride 
of zinc, and the nitrate of silver. These may be of ser- 
vice where, for any reason, a more radical operation is 
not admissible. Fuchsin and methyl-blue, either injected 
under the skin or locally applied, will sometimes seem to 
stay the progress of an epithelioma, but will not cure it. 

There are some cases that are too advanced for any 
active interference, and then palliative remedies only are 
permissible. 

Prognosis. The prognosis of epithelioma as to life is 
fairly good. While, as already said, there are some cases 
that are rapidly fatal, many do not seem to have any ef- 
fect on the patient's health for years. The prognosis as 
to cure is always doubtful. Some cases, whether excised 
or destroyed by other means, will return after a time. If 
they do return, they must be destroyed again. 



240 DISEASES OF TEE SKIN. 

Epithelioma Contagiosum. See Molluscum. 

Epithelioma, Multiple Benign Cystic. Under this title 
Fordyce places l those cases formerly described under the 
names of hydradenomes eruptifs, syringo-cystadenome, epi- 
thelioma adenoides cysticum, and others, and reports two 
additional cases. It is characterized by the eruption of 
small, pale-yellow, pearly, or pinkish tumors from pinhead- 
to pea-size, that are located on the face, chest, back, and 
upper extremities. They are firm to the touch, and pain- 
less. Some of the tumors are tense, shiny, freely movable, 
sometimes with a central depression. Some are trans- 
lucent, like vesicles ; some look more like milia. They 
slowly enlarge to the size of a pea and then remain sta- 
tionary. The disease has no effect on the general health. 
In some cases it seems to be hereditary. 

Microscopic examination shows the tumors to be made 
up of irregular masses and tracts of epithelial cells, and 
" cell-nests." Colloid degeneration of individual cells is 
also seen in the cell-masses. There is also a down growth 
and proliferation of the epidermis and external root-sheath 
of the hair follicle. It is supposed that the growths are 
due to misplaced epithelial cells of indifferent nature. 
(Fordyce.) Their treatment is by curetting. 

Epitheliomatose Pigmentaire. See Atrophoderma pig- 
mentosum. 

Equinia (E 2 k-wiV-i 2 -a 3 ). Synonyms : Glanders ; 
Farcy ; Malleus ; (Fr.) Morve ; (Ger.) Eotz. 

A contagious, specific disease, with general and local 
symptoms, derived from the horse, ass, or mule. 

This is a rare disease in the human race, and runs an 
acute, subacute, or chronic course. It is derived by inocu- 
lation with the bacillus mallei, and its symptoms show 
themselves in from three days to six weeks afterward. Its 
constitutional symptoms are fever, prostration, constipa- 
tion, and rheumatic pains, with the subsequent develop- 

1 Journ. Cutan. and Gen.-Urin. Dis., 1892, x., p. 459. 



ERYSIPELAS. 241 

ment of a typhoid condition in which the patient dies. 
The objective symptoms are a profuse purulent or sanious 
nasal discharge ; chancroidal ulceration at the site of en- 
trance of the poison ; phlegmonous inflammation of the 
aifected part ; adenitis ; and a cutaneous efflorescence. 
The latter is a disseminated eruption of red macules, 
which develop into yellow papules, upon which variola- 
like pustules and bulla? may form. These may coalesce 
into superficial ulcerations and gangrenous patches. In- 
filtration of the subcutaneous tissues may occur and deep 
sloughs may form. There may be a general adenitis, and 
the glands may break down and form ulcerating cavities. 
The whole skin may be involved in these destructive pro- 
cesses. 

Treatment is usually unavailing, and is on general prin- 
ciples. The prognosis is bad. The more acute the symp- 
toms the worse the outlook. 

Erbgrind. See Favus. 

Erysipelas (E 2 r-i 2 -si 2 p'-e 2 l-a 2 s). Synonyms : (Fr.) La 
rose, Feu sacre ; (Ger.) Rothlauf, Rose, Hautrose, Wund- 
rose ; (It.) Risipola ; St. Anthony's fire, Wildfire, Rose. 

An inflammatory disease of the skin or the adjacent 
mucous membranes, attended always with redness and 
swelling, and often with vesicles, bulla?, pustules, diffuse 
suppuration, and gangrene ; and characterized by a tend- 
ency to spread at the periphery and by fever. (Foster.) 

Symptoms. Though the most modern pathology 
teaches that erysipelas always originates in or about a 
lesion of the skin or mucous membrane, and is therefore 
allied to if not identical with the same disease as met with 
in surgical and lying-in wards, so-called surgical erysipelas 
will not be considered here. The outbreak of the disease 
is usually preceded for a day or so with malaise, and the 
attack is often ushered in with a chill, pyrexia, and vomit- 
ing. The fever is present throughout the whole course 
of the disease, excepting in the most mild type, when it 
may soon subside. The thermometric range is from 101° 
16 



242 DISEASES OF THE SKIN. 

to 105.5° F. There will be other signs of constitutional 
disturbance, such as a coated tongue, a quickened pulse, 
either full, soft, and compressible, or 7 in bad cases, small 
and weak ; headache, drowsiness, or, in bad cases, de- 
lirium .; and sometimes albumin is found in the urine. 

The most frequent location of the disease, so far as we 
now are concerned, is the head and face, though it may 
occur anywhere on the body. The eruption begins usually 
as a single patch, which is at once rosy red, swollen, 
sharply defined, irregularly shaped, hot to the touch, and, 
at first, with a smooth glazed surface. The redness may be 
removed by pressure, leaving a yellow stain, but promptly 
returns when the pressure is removed. The patch en- 
larges, creeping with more or less rapidity over the surface, 
always preserving its sharp, offctimes indented border that 
is raised toward the sound skin ; it becomes of a darker 
hue, sometimes livid; and very commonly, though not 
uniformly, vesicles or even blebs form on it. These latter 
may become purulent, and breakings discharge their con- 
tents upon the surface, which dries into crusts. As the 
process extends, the central portion becomes flattened and 
less red. Sometimes new patches may appear, and coalesce 
with the original patch. Sometimes, while spreading pe- 
ripherally, there may be a recrudescence in the older parts. 
The area of the disease may be limited or may include the 
whole body. Very often it seems to be checked by the 
line of the hair, whether of the beard or scalp. Not un- 
commonly it invades the hairy parts, involving one-half 
or the whole of the scalp and extending down upon the 
neck. Then the patient's appearance is indeed deplorable. 
His lips are swollen and livid, his eyelids are swollen so 
that the eyes cannot be opened, and his head seems enor- 
mously enlarged. At times there may be a lighting up of 
the disease on a distant part of the body, as on the arm 
with erysipelas of the face. The lymphatics and the lym- 
phatic glands are involved. The former often show them- 
selves as red streaks. The glands may suppurate, and 
gangrene of the skin may declare itself. All grades ol 



ERYSIPELAS. 243 

inflammation may be reached. Sometimes the disease is 
but slight, sometimes very severe, the constitutional symp- 
toms keeping pace with the severity of the local symptoms. 
The duration of the disease may be six or seven days, or 
two or three weeks. The patient is always more or less 
prostrated by it, though many of the cases we see are 
ambulant cases. 

The subjective symptoms are burning, tingling, itch- 
ing, and tension. The parts are often tender, and may be 
spontaneously painful. 

The disease quite commonly begins about the nose, and 
may invade the mouth. Occasionally it spreads rapidly 
over the surface as an advancing, broad, rosy red, raised 
line. Sometimes recurrent attacks occur at short inter- 
vals ; generally the disease does not recur. When the 
scalp is invaded, the hair commonly falls during conval- 
escence. Sometimes some lesion of the skin may be found 
as the starting-point of the inflammation, or perhaps some 
lesion of the mucous membrane of the nose, mouth, or 
ear. In the recurrent attacks the nose is quite commonly 
the pecant member. But in a very large proportion of 
cases no lesion at all will be discoverable. When the dis- 
ease subsides the skin desquamates, and returns at last 
to the normal condition. 

Erysipelas occurring upon the trunk or extremities pre- 
sents pretty much the same symptoms as when occurring 
upon the face. 

Etiology. It is now generally accepted that the dis- 
ease is infectious, and caused by a specific micro-organism 
that was described by Fehleisen. 1 This gains access to 
the body through some lesion of continuity of the skin, or 
mucous membrane, however minute that may be. As in 
many of the bacterial diseases, so in this one, it is probable 
that the patient must be in the proper condition of health, 
or rather ill-health, for the lodgement of cocci. One at- 
tack predisposes to another attack. It is more frequent 
in women than in men ; and in winter than in summer. 
Deutsche Zeitschrift far Chirurgie, 1882, xvi., 391. 



244 DISEASES OF THE SKIN. 

Intemperance, Bright' s disease, parturition, and a lowered 
state of nutrition predispose to it. While the contagious- 
ness of surgical erysipelas is well known, and commonly 
observed, it is rare to meet a case of facial erysipelas trace- 
able directly to contagion. The possibility of the occur- 
rence of the disease without infection by the micro- 
organism is still entertained. It has been thought to arise 
from taking cold or to begin in some circumscribed puru- 
lent deposit. 

There is nothing specific about the pathological anatomy 
of the disease. 

Diagnosis. If the clinical features of the disease are 
kept in mind, the sharply defined, swollen, red patch ad- 
vancing with more or less steadiness over the surface, the 
process being preceded by a chill and accompanied by 
marked constitutional disturbance, there is little danger of 
mistaking it. It may, however, be mistaken for an acute 
erythematous eczema, an erythema, or so-called giant urti- 
caria. In eczema the parts are not so swollen ; the margin 
of the patch fades into the surrounding skin ; the color is 
not so brilliant ; the surface is rougher and more scaly ; 
there is decided itching and a lack of constitutional dis- 
turbance of any magnitude. Erythema lacks the consti- 
tutional symptoms of erysipelas ; the redness fades com- 
pletely away under pressure, without leaving a yellowish 
stain, and springs back promptly when the pressure is re- 
moved ; it does not creep over the skin ; and it is of short 
duration. In urticaria there will usually be well-marked 
wheals or a history of them ; great itching ; no tenderness ; 
a short course ; a history or evidence of digestive disorders, 
and an absence of marked constitutional disturbance. 

Treatment. The great variety of remedies that have 
been vaunted for the cure of erysipelas evidences the fact 
that most cases recover of themselves. There are not a 
few competent observers who are skeptical of the real 
efficacy of any treatment. As the disease tends to lower 
the vitality of the patient we should strive to support his 
strength by a most nutritious diet, and by alcoholic stim- 



ERYSIPELAS. 245 

ulants in adynamic cases. The internal medication will 
be symptomatic to a large extent, by means of aconite, 
quinine, antipyrine, phenacetin, and the like. The tinc- 
ture of the chloride of iron, in twenty- to sixty-minim 
doses every two or three hours, is regarded by many as a 
specific, and should be given in all but the slightest cases. 
Jaborandi by the mouth, or pilocarpine, one-sixth to one- 
quarter grain hypodermically, have their advocates, but 
must not be thought of in debilitated subjects. 

The local treatment is very important. If there is a 
wound present, it should of course be thoroughly disin- 
fected on surgical principles. The lead and opium wash 
is an old remedy, and has proved useful in very many 
cases. It is composed of 

R. Liq. plumbi subacetat. dil., 3.j~i\i- 

Tinct. opii, 5y~i v - 

Aquae, ad Oj. M. 

It may be used hot or cold, whichever is most agreeable 
to the patient. Dry heat will also relieve the discomfort 
of the patient. Resorcin in watery solution of 2 or 3 per 
cent, strength seems at times to cut short the disease. 
Duckworth 1 commends chalk ointment made of equal 
parts of melted lard and chalk, with or without a half- 
drachm of pure carbolic acid to the ounce. This is to be 
smeared on thickly and covered with plain or boric lint. 
AYhite-lead paint has done well in some hands. White 2 
expects to cure his cases of ordinary facial erysipelas by 
keeping the part constantly covered with cloths saturated 
in the following : 

R . Ac. carbolici, 5J I 41 

Alcohol., 1 -- r\ o^a 

Aquae, } " 0ss ^ 2o ° M. 

It may be used every alternate hour. Carbolic acid 
may also be used in oil, 10 per cent, strength, and rubbed 
in every hour. PifPard recommends the external use of: 

1 Practitioner, January, 1887. 

2 Trans. Amer. Derm.' Asspc. , 1890, p. 42. 



246 DISEASES OF THE SKIN. 



Tinct. belladonna?, 


1 part. 


Glycerini, 


1 » 


Aquse, 


8 parts. 



M. 

Shoemaker is fond of the ointment of the oleate of bis- 
muth. Ichthyol, in 50 per cent, aqueous solution, is of 
wonderful efficacy. The parts should be constantly cov- 
ered with it. 

The treatment by scarifications about the patch, the in- 
cisions being made diagonally, partly in the sound and 
partly in the diseased skin, and then covered with gauze 
wet with a solution of bichloride of mercury, 1 in 1000, 
has of late been highly praised by many men. This is 
known as the Kraske-Biedel method, and should be al- 
ways thought of in grave cases. Woelfler l recommends 
compression of the border-line by adhesive-plaster strips, 
the disease seldom spreading beyond the constricting band. 
This is specially applicable to erysipelas of the limbs. 

Prognosis. Many cases of erysipelas recover of them- 
selves in a few days, while others may run a course of 
weeks. The prognosis may be said to be good in most 
cases ; but even in those that begin as mild ones we should 
be on the Avatch for grave symptoms. When the scalp is 
affected the prognosis is more grave than when the face 
alone is the seat of the disease. When the patient is the 
subject of chronic alcoholism, or Bright' s disease, or is in 
the puerperal state, the prognosis is bad. 

Erysipeloid is a term employed by Rosenbach to desig- 
nate an erysipelas-like eruption unattended by constitu- 
tional symptoms. It is also called chronic erysipelas and 
erythema migrans. It originates in a wound, is due to 
infection from some dead, putrefying animal substance, 
and chiefly affects cooks, butchers, fishmongers, and the 
like. It occurs mostly on the fingers, and spreads from 
the point of inoculation as a dark-red, often livid swelling 
with a sharp border. As it travels over the surface the 
central portion undergoes involution, and thus circles or 

1 Wiener klin. Wochenschr. , 1889, Nos. 23 and 25, 



ERYTHEMA HYPEBJEMICUM. 247 

scalloped patches may be formed. It stops spontaneously 
after from one to six weeks' duration. There is marked 
itching or burning during the whole course of the disease. 
It is distinguished from true erysipelas by the mildness of 
its symptoms. A salicylic acid or other antiseptic oint- 
ment may be used in treatment. 

Erythanthema (E^-r-tham'th^nia 3 ) is a term employed 
by Auspitz to designate a class of cutaueous efflorescences 
which have in common a basis of erythema. (Foster.) 

Erythema (E 2 r-i-the 2/ -ma 3 ). Synonyms : Dermatitis ery- 
thematosa, Erysipelas suffusum ; (Fr.) Ery theme, Dartre 
erythemoide ; (Ger.) Ery them, Hautrothe ; Rose rash. 

Erythema may be passive or active. The former is 
familiar as lividity of the skin, and the latter as blushing. 

There are many forms of erythema as a disease, but 
they may all be classed under one of two main varieties, 
namely : Erythema hyperaemicum and Erythema exuda- 
tivum. I shall follow Crocker's classification, as it is a 
practical one. It is a question whether erythema should 
be regarded as a disease or a symptom. 



' E. hyperaeniieuni 



Erythema 



(E. simplex. 
SEES* 



, E. lsve. 

[_ E. paratrininia. 



E. fugax. 
2. Due to internal J E. urticans, 
causes 1 E. roseola. 



E. searlatiniforme. 



E.exudat™ \ f ~*^ «■ 



E. multiforme. 
E. seu Herpes : 
E. nodosum. 
[E. gangrenosum. 

Erythema Hyperjemicum. 

This form of erythema is characterized by simple red- 
ness without swelling, and usually is not followed by des- 
quamation. This shows that it is due simply to a local- 
ized hyperemia without inflammation. It is always of 
short duration. The redness disappears under pressure, 
but springs back again as soon as the pressure is removed. 



248 DISEASES OF THE SKW. 

It occurs either in circumscribed patches of large or small 
size, or diffused over large areas. Subjective symptoms 
are often hardly noticeable. There may be some burning 
and tenderness, but there is never decided itching. The 
patient may rub his skin gently, but never scratches vio- 
lently. There may be slight constitutional symptoms 
with fever of mild grade, or some digestive disturbance, 
but these are not properly symptoms of the erythema, but 
rather of the underlying disease of which the eruption is 
but an accidental expression. For instance, two people 
may eat the same thing. In both there may be digestive 
disturbances. But one will have an erythema and the 
other will escape. 

This form of erythema may arise from either external 
or internal causes. Cases arising from external causes are 
localized, while those due to internal causes are general. 
Both are angio-neuroses, and predisposed to by an inborn 
susceptibility — that is, idiosyncrasy of the patient. 

In the first group Ave have Erythema simplex under 
which are included E. Traumatieum and E. caloricum, due 
to the rubbing of the clothing, the effect of heat or 
cold, as of the sun or wind, and of various vegetable or 
chemical irritants. Many of these simple erythemas I 
have already described under the caption of Dermatitis, 
which see. They are the simplest reaction of the skin 
to an irritant. If the irritant is great enough or lasts 
long enough we have a dermatitis set up. They are usu- 
ally localized, and for treatment require only the removal 
of the irritating cause, and the application of a simple 
dusting powder or ointment. The exciting cause con- 
tinuing we have inflammation added, and a dermatitis 
produced. 

Erythema Pernio has been described under Dermatitis 
Congelatio, which see. 

Erythema Intertrigo, or simply Intertrigo, is an ery- 
thema occurring between two folds of skin. It is most 
commonly seen in fat infants in the folds of the skin 
of the neck and joints. It is also encountered in adults 



ERYTHEMA HYPER. EMICUM. 249 

who are corpulent, and is often a very annoying trouble 
to women, where it frequently occurs underneath the 
hanomio; breasts. It also occurs between the scrotum and 
inside of the thighs, under the prepuce, in the furrows 
alongside of the vulva, in the joints, and all other skin- 
creases. It is caused by the friction in walking and 
favored bv heat and moisture. It is therefore more com- 
mon in warm weather. If not at once and properly 
attended to, the decomposition of the sweat and sebaceous 
matters will aggravate it ; and the irritation being con- 
tinued, an eczema will develop. It is, in infants, very 
common about the inside of the thighs, where the wet 
napkins cause and aggravate it. It is very often accom- 
panied by a disagreeable, cheesy odor, and, contrary to 
what obtains in other erythemas, there is exudation upon 
the skin in some cases. 

Diagnosis. The diagnosis from eczema is very often 
difficult. Indeed, they run into each other so imperceptibly 
at times that it is difficult to tell where erythema leaves off 
and eczema begins. But eczema itches more than ervthema, 
it tends to spread further beyond the affected part, and its 
exudation is not only sticky, but also stains and stiffens 
linen. The location in the skin-folds should suggest an 
intertrigo. Happily, the differentiation is a matter of no 
great importance as the same treatment is applicable to 
both. 

In infantile syphilis we frequently have an eruption 
upon the buttocks and inside of the thighs that bears a 
decided resemblance to intertrigo. Here a correct diag- 
nosis is of great importance. In syphilis the redness 
commonly extends down the whole inside of the legs to 
the feet and soles, it is of a darker color, and there will 
be other symptoms of the disease, such as snuffles, large 
or small papules to the outside of the red patch, mucous 
patches, and the like. In iniant asylums, where a great 
number of debilitated as well as syphilitic children are 
received, opportunities for the differentiation between 
syphilis and intertrigo frequently occur. 



250 DISEASES OF THE SKIN. 

Treatment. The treatment of intertrigo is simple. 
The opposing surfaces of skin must be separated by pieces 
of lint, the furrows must be kept perfectly clean, and 
dusting powders of starch, talc, lycopodium, and the like 
must be freely used. To these powders oxide of zinc, 
boric acid, or other astringents may be added, the com- 
pound stearate of zinc being one of the best applications. 
Hardaway recommends : 

R. Thymol., gr. j. 

Pulv. zinci oleat., §j. M. 

As a rule, powders answer better than ointments, though 
Lassar's paste, as given under Eczema, may be used. 
Lotions are preferable to ointments, such as calamine lo- 
tion, and saturated solution of boric acid. The treatment 
of intertrigo in infants is to be managed in the same way 
as eczema. (See under Eczema infantile.) 

Erythema Lceve is an obsolete term, which was employed 
to indicate the redness seen on (edematous limbs. 

Erythema Paratrimma belongs to the same category, 
only here it is the redness over bony prominences, as 
that preceding a bedsore. 

We have now to consider the second group of erythema 
hypersemicum, those erythemas which are due to internal 
causes. Here might be placed all the exanthematous 
fevers, as well as the drug-eruptions. But the first of 
these belongs to the domain of general medicine, and the 
last will be found under Dermatitis medicamentosa. 

Erythema Fiigax is, as its name indicates, a fugitive 
erythema — as it were, a prolonged blush. It is seen most 
often in children with some digestive disturbance, and its 
chosen location is the face. It lasts for a few moments or 
hours, and is seldom seen by the physician, although he 
will be told, not infrequently, by patients that they are 
annoyed by a flushing of the face after eating, exposure 
to cold, or mental emotion. It is to be managed like 
Urticaria, which see. 



ERYTHEMA HYPFR.EMTCUM. 251 

Erythema Urticans is simply the first stage of urticaria. 
The term should be dropped. 

Erythema Roseola, or simply roseola. "While children 
are more subject to this form of erythema than adults are, 
it may occur in the latter. Most commonly it affects the 
whole body, but it may be localized. As it is due in most, 
if not all, cases to digestive disorders or other constitu- 
tional disturbance, it is usually ushered in with a rise of 
temperature, which may be pretty sharp, 103° or 104° F., 
furred tongue, restlessness, and the like. Soon the erup- 
tion appears, which may be a blotchy redness, or in faintly 
marked papules, or in rings, or gyrate figures. The erup- 
tion lasts a few hours only, or, coming and going in differ- 
ent places, it may be prolonged for a few days. Besides 
digestive disorders, gout, changes of temperature, and the 
seasons of spring and autumn have been assigned as causes. 

Diagnosis. In itself it is a matter of little moment, 
but as it resembles scarlet fever, rotheln, and measles, its 
diagnosis is important. It differs from scarlatina in not 
having such severe constitutional symptoms ; in an absence 
of the strawberry tongue, swollen, reddened fauces, and 
enlarged glands ; in the rash coming out all over the body 
without following any regular course of development from 
the neck downward ; in the eruption being blotchy or 
papular, and not a diffused redness. After watching the 
case for a day the diagnosis will be evident by the clear- 
ing away of the disease wholly or partially. It differs 
from measles in an entire absence of catarrhal symptoms, 
and in its eruption not being crescentic, as well as in the 
irregularity of its course, the mildness of its symptoms, 
and the brightness of its color. It bears most resemblance 
to rotheln, and probably the two are often confounded. If 
there is a clear history of contagion, or more than one 
member of the family affected at the same time, the diag- 
nosis of rotheln is at once established. Rotheln is more 
pronounced on the extremities, and the lesions are of a 
more stable character. In case of doubt as to diagnosis 



252 DISEASES OF THE SKIN. 

of roseola the patient should be regarded as having a 
contagious disease, isolated and carefully watched. 

Treatment. Little need be done for the patient but 
to give a laxative, and to relieve symptoms. 

Erythema Neonatorum makes its appearance in the first 
few days of life, and is thought to be due to the influence 
of external and unusual irritants acting upon the tender 
skin of a newborn child. " The eruption consists of very 
minute red papules, seated upon a hypersemic base, which 
can be made to lose their color upon pressure. The lesions 
are most pronounced upon the back and breast, and fade 
away in a few days with slight desquamation of the most 
congested spots. The mucous membranes are unaffected, 
and there is no evidence of systemic reaction." (Hard- 
away.) 

Erythema Scarlatiniforme. A scarlatina-like erythema 
follows the ingestion of a number of drugs, and has been 
frequently mentioned in the section on Dermatitis medica- 
mentosa. The French authors describe a scarlatiniform 
erythema under the name of Erythemes scarlatiniformes 
recidivantes, which, according to Besnier, 1 who has pub- 
lished an excellent study of the affection, was first described 
by Fereol in 1876, at the Societe Medicale de Hopitaux 
de Paris. The disease is marked by redness, desquama- 
tion, and relapses. Its outbreak may or may not be pre- 
ceded for one or two days by malaise and slight febrile 
movement. It begins on the trunk and invades the whole 
surface in a few hours or in two days. It is a diffused, 
uniform, intense, scarlatinal, or sombre-red eruption. 
There may be slight differences in the shade of color, or 
the redness may be punctate, or some pinhead vesicles 
may develop upon it. Sometimes the eruption is limited 
to a certain portion of the body ; sometimes the eruption 
is general, but not universal, normal islands of skin being 
found in the general redness. It comes out in patches 
that run together. There is generally redness of the 
mucous membrane of the mouth and fauces. There is no 
1 Ann. de derm, et syph., 1890, L, 1. 



ERYTHEMA HYPEILEMICUM. 253 

thickening of the skin nor infiltration of mucous mem- 
branes. The skin burns, and there may be itching. Ex- 
foliation of the skin begins almost as soon as the eruption 
is out, commencing at the point of invasion. The des- 
quamation is general, and may be furfuraceous, or abundant 
and in large plaques. Upou the scalp it is furfuraceous. 
The Avhole process may take but one or two clays, or it 
may be prolonged for a month or six weeks. The hair 
and nails may be shed. The tongue is furred, and may 
desquamate, but never presents the papillae of scarlatina. 
After the beginning; of the attack there is usually no fever, 
and the appetite is preserved. There may be albuminuria 
during the attack. The relapses, which are apt to occur 
after intervals of days, months, or years, are less pro- 
nounced and the patient's health is good in the interim. 

Etiology. The cause of the disease is very often 
obscure. The first attack has been observed to follow 
exposure to cold, the application of mercurial ointment, 
or the action of some other irritant. But it is difficult 
to explain why from such causes relapses should occur. 
Besnier thinks that in some cases the cause is a poison 
developed within the individual. In this way he would 
explain some of the erythemas developing during an acute 
urethritis, which some observers claim may arise inde- 
pendently of the taking of copaiba. Scarlatiniform ery- 
themas occur occasionally in septicemic conditions, in 
typhus fever, in malaria of children, in sewer-gas poison- 
ing, and in various other conditions. 

Diagnosis. Brocq considers scarlatiniform erythema 
as one form of dermatitis exfoliativa, but it is distinguished 
from it by an absence of evening rise of temperature, by 
haying no permanent effect upon the health, by running a 
shorter course, and by the skin not being dry, contracted, 
and shrivelled. It differs from scarlatina in the mildness 
of its constitutional symptoms ; by the course of the erup- 
tion ; by the absence of tumefaction of the fauces, and 
the strawberry tongue ; by the early desquamation ; by 
not being contagious ; and by its tendency to relapse. If 



254 DISEASES OF THE SKIN. 

there is any doubt as to the diagnosis, the patient should 
be isolated. It differs from erythematous eczema in an 
entire absence both of thickening and moisture ; in being 
less itchy ; and in its rapid course. 

Treatment. The treatment is purely symptomatic. 

Erythema Exudativum. 

The second variety of erythema differs from erythema 
hypersenricum in the presence of an exudation into, not 
on, the skin, so that the patches are raised above the level 
of the skin, and in never involving the whole surface, but 
always occurring in circumscribed patches. It is an in- 
flammatory disease. Its several varieties are alike in 
that the redness disappears under pressure, to return at 
once when the pressure is removed. It is probable that 
erythema nodosum is really but a part, of erythema mul- 
tiforme, as the two forms may be present at one time. 
But it is usually described apart, and although this may 
not be strictly accurate, it is convenient. 

Erythema (Exudatimim) Multiforme, as its name indi- 
cates, is very multiform in its efflorescences. For a day or 
a few days before they appear there is some constitutional 
disturbance. This may be nothing more than slight ma- 
laise, the patient not feeling as well as usual. From these 
indefinite symptoms there are all grades up to fever of 
104° F., headache, gastric disturbances, and severe mus- 
cular and articular pains like rheumatism. According to 
Besnier and Doyon, an erythema of the pharynx, or a 
pharyngitis, laryngitis, or bronchitis, often precedes or ac- 
companies the outbreak of the eruption upon the skin. 
The eruption is most constantly seen upon the backs of 
the hands and feet, and here it commonly begins, though 
this is denied by Polotebnoff, to whom we are indebted for 
a most exhaustive and able study of erythema. 1 It also 
appears on the trunk and extremities more or less gener- 
ally, coming out in crops, and preserving a rough sym- 

1 Zur Lehre von den Erythemen. Hamburg, 1887. 



ERYTHEMA EXUDATIVTJM. 255 

metry. Sometimes it may remain confined to a single 
region, as the backs of the hands. Sometimes it occurs on 
the mucous membranes, as of the mouth and eyes. It is 
usually most marked and abundant about the joints should 
they have exhibited rheumatic pains. It is rare not to 
find lesions upon the backs of the hands. With the ap- 
pearance of the eruption there is a subsidence of the con- 
stitutional symptoms, though in many cases the patients 
are more or less definitely ill during the whole course of 
the disease. 

The eruption commences as a group of deep-red papules 
from pinhead- to pea-size, conical or rounded, and this is 
called Erythema papulation. The eruption may continue 
as such ; or the papules may coalesce and form elevated 
patches, sharply marked against the sound skin ; or they 
may enlarge to the size of tubercles, thus forming erythema 
tuberculatum. If they still continue to enlarge, they be- 
come depressed in the center and ring-shaped, the periph- 
ery being deep-red while the center is purplish. This 
is called erythema cireinatum or annulare. Sometimes it 
happens that the ring still enlarges by successive exuda- 
tions, and then we will have ring within ring, the outer 
one pink, the next red, the next purplish, thus forming an 
iris-like play of colors that has been termed erythema iris. 
Two rings near each other and enlarging will after a time 
meet at the peripheries, the points of contact will melt into 
each other and disappear, and then we shall have a large 
patch with a figure-of-eight or scalloped, raised border and 
a flattened center. This is called erythema marginatum. 
It may travel over a large part of the trunk or the cir- 
cumference of a limb, leaving a fawn-colored pigmenta- 
tion, which soon fades. Or two rings meet, and each 
breaks, and only a gyrate line is formed, to which the 
name of erythema gyratum is applied. Sometimes, though 
rarely, the exudation is so abundant that the epidermis is 
raised in the form of vesicles or bullae. This is erythema 
vesiculosum, seu buUosum. Hemorrhage may take place 
into the bullae. 



256 DISEASES OF THE SKIN. 

It is uncommon to find all these forms present at the 
same time, nor must it be understood that one form neces- 
sarily evolves into the other. The evolution may stop at 
any stage ; most often at the papular stage. Neverthe- 
less, more than one form is usually to be seen, so that the 
term multiform is merited. Crocker says that in children 
multiformity is less the rule, the constitutional symptoms 
are more pronounced, and if vesiculation occur, the vesi- 
cles are more prone to become purulent and leave scars. 

The duration of the disease is from two to four weeks, 
but it may be extended by a succession of outbreaks for 
months or years. The eruption is attended by burning, 
rather than itching, and sometimes by a feeling of tension. 
Slight pigmentation may be left, but it is transitory. 
Desquamation may follow the eruption, but is not com- 
mon. In some patients there is a decided tendency to 
relapse at irregular intervals for years. In Prof. George 
Henry Fox's service at the Vanderbilt Clinic I have seen 
a boy with a relapsing bullous erythema of the face and 
ears that had appeared at intervals during ten years. The 
bullae were of large size, fully distended, and of irregular 
shape. They left depressed, pigmented cicatrices in some 
places. Similar cases have been reported by others, as, 
for instance, by Hardaway, who saw one case with re- 
lapses for four years ; and T. C. Fox, who saw two cases 
with a duration of sixteen years in each case. 

As complications of erythema multiforme, and espe- 
cially of erythema nodosum, have been reported endo- 
and peri-carclitis, meningitis, pleurisy, pneumonia, and the 
like, but it is better to regard these diseases not as com- 
plicating the erythema, but as the primary diseases of 
which the erythema is a phenomenon. 

Erythema Iris. This very rare disease was formerly re- 
garded as a herpes, and is described in most text-books as 
herpes iris. Its other synonyms are hydroa, herpes circi- 
natus, and hydroa vesiculeux. It is only a form of ery- 
thema multiforme. It is seen sometimes along with other 
manifestations of erythema multiforme, or with herpes, 



ERYTHEMA EXUDATIVUM. 257 

though it usually occurs alone. It is located most often 
upon the backs of the hands and feet, and upon the arms 
and legs, but it may occur anywhere upon the skin as well 
as the mucous membranes. I have seen one case upon 
the buttocks as well as upon the elbows. According to 
Crocker, there are two varieties of the disease, one with a 
central vesicle or a purplish depression surrounded by one 
or more whitish rings slightly raised up by effused fluid ; 
the other with a central bulla with one or more rings of 
more or less discrete vesicles round it. Of these two the 
first is the more frequent. 

The first variety begins as a small erythematous papule 
upon which a pinhead-sized conical vesicle forms in about 
twelve hours. The vesicle grows larger and flattens, but 
preserves a red areola. When about a quarter of an inch 
in diameter the fluid is absorbed in the center, leaving a 
purplish depression ; or only a ring of absorption occurs, 
so that there will remain a vesicle in the center with a 
purplish zone about it, then a raised white ring, and 
around all a narrow, pink areola. This play of colors 
gives the name of iris. The patch may reach the diameter 
of half an inch, and then undergo involution ; or several 
patches may unite and form patches of one inch or more 
in diameter, and hemorrhage may take place into the 
bullae that may form. 

In the second variety, which is the hydroa vesiculeux 
of Bazin, round a central bulla a ring of split-pea-sized 
vesicles forms, the vesicles being either discrete or touch- 
ing. A second or a third ring of vesicles may form out- 
side of these, the skin between them being of a purplish 
tint. The bullae and vesicles may leave scars. Crusting 
also takes place from the breaking or drying of the vesi- 
cles. 

The lesions of both varieties are more or less symmet- 
rical, though a patch may develop on one side several 
days before the other. The duration is from three to four 
weeks or longer. Relapses are common. Burning is 
usually pronounced, and there n>ay be some itching. 
17 



258 DISEASES OF THE SKIN. 

From, this description it will be seen that the so-called 
herpes iris is really an erythema. 

Erythema Nodosum, also called dermatitis contusiforme, 
and erytheme noueux (Fr.), is more common than ery- 
thema iris, but not nearly so common as erythema multi- 
forme. It is only a variety of erythema multiforme, as 
it may occur as a part of that disorder. In the vast ma- 
jority of cases it occurs alone. Its prodromal symptoms 
are substantially the same as those of erythema multi- 
forme, but its rheumatic pains are more pronounced and 
always present. There are also tenderness and pain over 
the tibiae. After a few days of proclromata, round or, 
more often, oval, bright or rosy-red swellings appear over 
the tibiae, with their long axis vertical. These are from 
nut- to egg-size ; raised ; their borders merge gradually into 
the surrounding skin ; they are painful and often exqui- 
sitely tender ; firm at first, but may be semi-fluctuating 
afterward ; and their color darkens to a dark red, then 
purple, and in undergoing absorption they present the 
appearance of a black-ancl-blue spot from a bruise. The 
color at first disappears under pressure, to spring back 
when the pressure is removed. The changes of color 
subsequently seen are due to the gradual absorption of 
the coloring-matters of the blood deposited in the tissues. 
There are usually not more than a dozen lesions, gener- 
ally less. They are most frequently located over the 
tibiae, but may occur as well upon the arms, scapulae, 
thighs, and mucous membranes. They are roughly sym- 
metrical. The duration of the disease is, like that of 
other erythemas, two to four weeks. 

Etiology. The causes of erythema exudativum are 
not fully determined. It is probably due to some toxic 
condition of the blood, which may develop in the indi- 
vidual or be derived from without. It occurs more com- 
monly in women than in men, and in young adults rather 
than in old people, while erythema nodosum is said to be 
most frequent in children. It is most frequent in the 
spring and autumn seasons, in which dampness and cold 



ERYTHEMA EXUDATIVUM. 259 

winds prevail, and sudden changes of temperature are com- 
mon. The papular erythema is very often seen in recently- 
arrived immigrants. Rheumatism has a well-marked 
causal relation to erythema nodosum, and, it may be, to 
the other forms. Syphilis seems to be an etiological factor 
of some weight in the production of erythema nodosum. 
Some years ago I saw in the service of Professor E. B. 
Bronson, in the New York Polyclinic, a well-marked in- 
stance of this in the course of recent syphilis in a woman. 
Many cases seem to be due to systemic poisoning either 
by some infectious disease or by auto-infection. Some 
authorities are of the opinion that such cases should be 
separated from erythema exudativum and propose the 
name of polymorphous erythema. It is seen with cholera, 
influenza, and the exanthemata ; with indigestion, preg- 
nancy, parturition, menstrual disturbances, kidney dis- 
eases, and various other internal or systemic disorders. 
Sometimes the disease seems to be a pure angio-neurosis. 
Cases of erythema multiforme recurring with recurring 
attacks of gonorrhoea have been reported. These appear 
as reflex angio-neuroses without the ingestion of balsamics 
in the treatment of the urethritis. Cases of erythema 
multiforme not infrequently follow the ingestion of drugs ; 
at least they are almost identical with it in appearance. 
Sometimes, according to Polotebnoff, it seems to be an 
abortive form of prevailing epidemics. Cases certainly 
should be watched carefully in connection with other 
symptoms, as they may be but part of the prodromata of 
some grave disorder. I have seen two cases in which a 
well-marked erythema multiforme preceded for about ten 
days the outbreak of typhoid fever ; the erythema then 
disappearing and the characteristic typhoid eruption com- 
ing in due course. Many of the subjects of erythema 
are debilitated. Individual predisposition probably plays 
an important role in the etiology of some cases, especially 
in the relapsing ones. 

Pathology. All forms of the disease show not only 
hyperemia, but also inflammatory / effusion both of fluid 



260 DISEASES OF TEE SKIN. 

and leucocytes. Upon the amount of this fluid depends 
the character of the lesion. If small in amount, it will 
simply push up the epidermis into a papule or tubercle ; 
if of larger amount, we shall have vesicles and bullae. 
There is also an escape of the coloring-matter of the 
blood into the tissues. (Crocker.) 

Diagnosis. If the characteristics of erythema multi- 
forme are borne in mind, little difficulty in diagnosis will 
arise. These are the sudden occurrence of raised, bright, 
or rosy-red lesions, located by preference upon the backs of 
the hands and feet ; and the color that fades away entirely 
under pressure, to return again when pressure is removed, 
and in disappearing leaves stains. It most resembles ur- 
ticaria, but differs from it in having more stable lesions of 
more varied shape ; in absence of wheals ; in occurring 
particularly on the backs of the hands and feet ; and in 
burning rather than itching. The papular form differs 
from papular eczema in its chosen locations ; in its burn- 
ing rather than itching ; in its papules being larger and 
never developing vesicles nor forming patches ; in an ab- 
sence of thickening of the skin ; in disappearing com- 
pletely under pressure ; in tending to get well without 
treatment ; and in leaving stains. The nodes of erythema 
nodosum differ from syphilitic gummata in occurring sud- 
denly and not gradually. In syphilis the redness does 
not occur until after the node has existed for some time, 
and the nodes are not tender nor developed symmetrically. 
Moreover there would be other evidences of syphilis. 

Treatment. Villemin x maintains that iodide of po- 
tassium, in doses of at least thirty grains a day, is almost 
a specific, and will abort relapses. The experience of 
Besnier and others has not been in accord with that of Vil- 
lemin. Quinine, twenty to thirty grains a day, and salicy- 
late of soda in fifteen-grain doses three or four times a day 
sometimes abort or check the disease. Arsenic may be 
tried in chronic cases. The treatment is mainly sympto- 
matic, and directed to relieving the constipation, regulat- 
] Gaz. hebdom., May 24, 1886. 



ERYTHEMA ELEVATUM DIUTINUM. 261 

ing the diet, aiding digestion, ameliorating rheumatism, or 
toning up the system. In obstinate cases the patient had 
best be kept in bed. Locally any alkaline lotion will 
afford relief, such as 

R. Pulr. calamin. prep., 3ij; 4 

Zinci oxid., 5 SS ! 3 

Liq. calcis, gij; 100 M. 



Or, 



R. Liquor plnmbi subacetatis, ^l^v; 3| 

Aqua-, 5J; 100 M. 



Or, lead and opium wash, hamamelis, and other evapora- 
ting solutions. Ointments should be avoided, as they do 
no better than lotions and are disagreeable to use. 

Sometimes a simple dusting powder ^vill do as well. In 
erythema nodosum the patient should be kept in bed, and 
often the lotion is more agreeable to the patient when used 
warm. Salicylic acid or salicylate of soda internally may 
afford relief to the sometimes intense pains. Regulation 
and simplification of the diet, and the administration of 
diuretics or tonics, according to the nature of the case, 
will do good in the disease as seen in immigrants. 

Prognosis. The disease tends to spontaneous cure. 
Relapses may be expected, though they are by no means 
the rule. Exceptionally the disease may run a protracted 
course, but recovery may be expected. 

Erythema Centrifuge. See Lupus erythematosus. 

Erythema Elevatum Diutinum. Under this caption 
Crocker T and others describe a form of erythema that is 
said to occur in girls with a rheumatic history. It de- 
velops over the articular prominences of the fingers, el- 
bows, and knees, and also on the palms, toes, and buttocks. 
Its lesions are nodular, with a tendency to coalesce into 
elevated infiltrations that are most marked on the palms. 
They tend to persist, but may undergo involution. Their 
color is at first pink, but soon becomes purple. The older 

1 Brit. Journ. Dermat, 1894, vi., 1. 



262 DISEASES OF THE SKIN. 

lesions become firm and almost cartilaginous, and are 
always incompressible. The lesions are always sharply 
defined against the skin. Microscopically they are an 
inflammatory process accompanied by the production of 
fibrous tissue. 

Erythema Gangrenosum, though described as a disease, 
is probably, in most instances, a feigned eruption. In it 
rosy, irregular patches appear on different parts of the 
trunk and extremities, which, at first smooth, after a few 
days become dry and harsh and covered with a thin scale. 

Erythema Induratum is a disease first described by 
Bazin as erytheme indure des scrofuleux. It consists in 
an eruption of nodular lesions that may remain deep-seated 
for a considerable time, so that they can be made out only 
by palpation. After a while the overlying skin becomes 
red, and later violaceous, and they resemble erythema 
nodosum. In size they vary from that of a hazelnut or 
larger on the legs, to smaller on the fingers. They are 
round or ovoid in shape. They are usually few in number 
and discrete, but may be numerous and confluent. They 
are indolent in their course, and may undergo involution, 
or suppurate, or necrose en masse. Polycyclic ulcers may 
form. There may or may not be pain or tenderness. 
They are located most often on the legs in young people, 
especially in girls of poor general health and circulation, 
and who suffer from chilblains in winter. 

They differ from erythema nodosum in their more cir- 
cumscribed form, firmer consistence, darker color, deeper 
seat, absence of tenderness, tendency to ulcerate, and more 
protracted course. Syphilitic gummata are not bilateral, 
and usually other symptoms of syphilis can be found. 

The treatment consists in rest in bed, elevation and com- 
pression of the legs, and general tonics. 

Erythema Mamelonne. See Erythema roseola. 

Erythema Migrans. See Erysipeloid. 

Erytheme Noueux. See Erythema nodosum. 



EBYTHBASMA. 263 

Erytheme Papuleux Desquamatif (Yidal). See Pityri- 
asis maculata et circinata. 

Erythrasma (E 2 r-i 2 -tlira 2 z-ma 3 ). A contagious parasitic 
disease of the skin, occurring especially in the groins and 
axilla? in the form of sharply defined, brownish-red, des- 
quamating patches, bordered by a fringe of broken and 
partly detached epidermis. (Foster.) 

The disease begins as a little yellowish point that soon 
becomes a lentil-sized macule, and grows into a patch the 
size of a silver dollar or the hand. Several patches join 
together so that large surfaces may be involved. The 
patches are oval or disk-shaped. They are located in the 
situations where intertrigo is liable to occur, such as the 
axillae, groins, and where the scrotum comes in contact 
with the thighs. The latter situation is declared by 
Besnier to be nearly always the original site of the disease. 
From these favorite locations the disease may spread to 
the chest, abdomen, or thighs. Besnier 1 met with a case 
involving the thigh down to the knee. The color of the 
patches is orange, red, yellowish, or brownish, or, in the 
folds of the skin, pale red. Their outline is sometimes 
marked by a raising of the epidermis. Their surface is 
dull-looking, and feels less smooth than normal. They 
are quite tenacious, cannot be readily rubbed off, and show 
little tendency to spontaneous recovery. There may be 
slight itching, and a very little delicate scaling. 

Etiology. The disease occurs most often in men, and 
never in children. It is due to a parasite called the mi- 
orosporon minutissimum which is described by Balzer 2 as 
consisting of long wavy mycelia, that are rarely branched ; 
and of very fine spores. High powers of the microscope 
are necessary to see them. They are located exclusively 
in the corneous layer of the skin. He regards them as a 
common form of parasite that produces the disease in 
some people only on account of the peculiar fermentation 
of their skin secretions. 

1 Journ. de Med. et de Chirarg. prat., 1883, liv., 351. 

2 Ann. de derm, et syph., 1884, v., 597, 



264 DISEASES OF THE SKIN. 

Diagnosis. The disease resembles chromophytosis, 
eczema marginatum, and chloasma. It differs from 
chromophytosis by the darkness of its color ; by the ab- 
sence of distinct rather large scales that can be lifted by 
the nail ; by its location, sparing the trunk, except by 
extension ; and by the character of the microscopical ap- 
pearances. From eczema marginatum it is distinguished 
by an absence of all inflammatory symptoms, by not being 
more pronounced at the periphery than at the center, and 
by the microscopical appearances. From chloasma it dif- 
fers by being a parasitic and not a pigmentary disease, and 
by the change it causes in the feel and texture of the skin, 
and by the effect of treatment. 

Treatment. It is curable by the same means as is 
chromophytosis, namely, by the tincture of iodine ; pyro- 
gallol ; chrysarobin ; bichloride of mercury ; or sulphur. 
It is more obstinate than is chromophytosis, and quite as 
prone to relapse unless thoroughly eradicated. 

Erythromelalgia (EV-P-thro-me^-a^'-gP-a 3 ) is a nerv- 
ous disease characterized by the appearance of a persistent 
patch of congestion, often on the sole of the foot, attended 
with swelling and pain. (Foster.) 

Esthiomene (E 2 s-te-o-me 2 n). This is a disease of the 
ano vulvar region that was described by Hnguier, 1 and 
about which there is a good deal of uncertainty. It has 
been variously considered as a form of lupus, syphilis, 
elephantiasis, and epithelioma. " It is characterized by a 
leaden or violaceous hue of the parts, and their simultane- 
ous alteration of shape, induration, thickening, ulceration, 
destruction, hypertrophy, and infiltration, so that the ori- 
fices and canals of the vulvo-anal region may be at the 
same time ulcerated, enlarged, and constricted, and its 
grooves and cutaneous and mucous folds exaggerated, 
thickened, and the seat of more or less extensive and deep 
ulcerations and cicatrices ; without pain, without directly 

iMem. de T Acad, de Med., 1869, p. 507. 



FAVUS. 265 

threatening life, and for a long time without affecting the 
constitution." (Foster.) 

Exanthematous Fevers. Consideration of the constitu- 
tional symptoms, the distribution of the eruption, and the 
course of the disease in question should leave little doubt 
as to diagnosis, and in any event watching the case for a 
day or so will decide it positively. See also Morbilli, 
Scarlatina, Rotheln, etc. 

Farcy. See Equinia. 

Favus (Fa 3/ -vu 3 s). Synonyms : Porrigo lupinosa, seu 
favosa, seu lavalis, seu scutulata ; Porrigophyta ; Tinea 
favosa, seu vera, seu ficosa, seu lupinosa, seu maligna ; 
Trichomykosis or Dermatomycosis favosa ; (Fr.) Teigne 
faveuse, teigne du pauvre ; (Ger.) Erbgrind ; Crusted or 
honeycomb ringworm, Scall head, True porrigo. 

A contagious vegetable parasitic disease due to the 
AchoricHi Schoenleinii, and characterized by the presence of 
discrete or confluent, circular, pale sulphur-yellow cupped 
crusts, or by asbestos-like masses of grayish friable crusts ; 
by loss of hair producing irregularly shaped, disseminated, 
red, bald patches ; by permanent atrophy of the scalp ; 
and by running a chronic course. 

Symptoms. Favus affects both the scalp and the non- 
hairy skin as well as the nails and mucous membrane. 
We shall first describe it as it affects the scalp. It begins 
either as one or more scaly erythematous spots ; or as 
minute yellowish puncta ; or as a group of vesicles smaller 
than those met with in ringworm. These develop into 
small sulphur-yellow cupped crusts about the hairs. 
When the case is seen by the physician the early stage is 
usually passed, and he will find that the hair is dry and 
lustreless, and has fallen out in places, leaving irregularly 
shaped bald patches, of all sizes, and of pronounced red 
color. Upon both the bald patches and the parts still 
covered with hair the sulphur-yellow cup or saucer-shaped 
crusts will be found, with raised or rounded edges, and 
with one or several hairs growing out of the middle of 



266 



DISEASES OF THE SKIN. 



them. There will be more or less scaling, and, if the 
disease be of some age, thick mortar-like crusts of grayish 
color. In some cases when first seen it may be impossi- 
ble to find the characteristic crusts, scutula as they are 
called, they being obscured by the mortar-like masses. 
In some cases the scutula are wanting. If we approach 

Fig. 24. 




Favus capitis. (Fox. 1 ) 

near enough to the patient, we will appreciate a peculiar 
odor variously described as that of mice, straw, or of a 
menagerie. 

The crusts, scutula, or favi are situated about the hair 

l Q, H. Fox. Skin Diseases of Children, N. Y., 1897, 



FAVUS. 267 

follicles. They are from pinhead- to split-pea-size, ac- 
cording to age. At first they are covered with a thin 
layer of epidermis, but later the edges are free. "When 
they are picked off they leave a moist depression which 
soon fills up, or a pustule, or an atrophied spot. The 
color is pale or sulphur-yellow, or, if of long standing, it 
may be a dirty or greenish-yellow. The crusts are dis- 
crete and disseminated or grouped ; sometimes they coa- 
lesce ; they are firm to the touch, and when crushed be- 
tween the fingers impart a feeling of crumbling like 
mortar. There is a slight zone of redness about them. 
Though they may not be seen at the first examination, if 
the scalp is cleaned off and left to itself they will form in 
the course of two or three weeks. The baldness is rarely 
in well-defined patches. The patches may be few in 
number, or so numerous that the hair occurs only in 
islands. At first their color is inflammatory red ; later 
they become white and atrophic in appearance. The 
baldness is permanent. The hair is dry from the first ; 
later it becomes brittle and split longitudinally ; but it is 
never so easily broken as in ringworm, and can easily be 
pulled out with its roots. There is itching of the scalp. 
That is the only subjective symptom. Pustulation does 
not belong to the disease, but may be an accidental com- 
plication. Other complications that may arise are pedicu- 
losis, eczema, and enlargement of the cervical glands. 

Occurring upon non-hairy parts it undergoes materially 
the same development and forms the characteristic cups. 
Sometimes it will take the circular form of a ringworm 
with the development of vesicles, and resemble it very 
closely, only that the cups will be sure to develop some- 
where. (Figs. 25, 2(3, and 27.) The scutula develop 
around the lanugo hairs. There may be only one patch 
of favus or a large part of the body will be covered by 
the fungous growth in the form of sulphur-yellow cupped 
crusts and asbestos-like masses. On the non-hairy parts 
the disease is easier of cure than on the scalp, and is not 
so apt to leave scars. In a single case, that of Kaposi, 



268 



DISEASES OF THE SKIN. 



the fa vie fungus was found implanted upon the mucous 
membrane of the stomach. The nails may be affected, 
either in the form of onychitis beginning at the side of 
the nail, hardly distinguishable from the same disease de- 
veloped from common causes ; or in having a scutulum 
develop in the nail-bed and showing through the nail. 
This is rare. The occurrence of favus upon the head 
will give a clue to the origin of the onychitis. 

Etiology. The disease is due to the implantation and 
growth of the Achorion Schoenleinii primarily in the scalp 

Fig. 25. 




Favus of knee. 

and secondarily in the hair. It is contagious, but not so 
much so as is ringworm. It used to be rare in this city, 
but on account of its being constantly imported from 
Europe the disease is on the increase, and cases are begin- 
ning to occur in native Americans. Its course is very 
chronic, and it shows less tendency than ringworm does 
to spontaneous recovery about the time of puberty. 
Though children are more commonly affected than are 
adults, it is by no means uncommon to see it in full ac- 



FAVUS. 

Fig. 26. 



269 




Case of favus of hand snowing scutula. Side view. 



Fig. 27. 




Favus of hand. Front view. 



270 



DISEASES OF THE SKIN. 



tivity in people well advanced in life. It has been as- 
serted that the strumous diathesis predisposes to favus, 
but this is doubtful. Like all other parasites it requires 
a certain soil upon which to grow, and does not affect all 
skins. It is a disease common in mice, and may occur in 
rabbits, dogs, cats, and fowls, and be a source of contagion 
for the human race. 

Pathology. The cups are composed almost wholly of 
the fungus, which consists of flat, narrow, branching, and 
inosculating mycelial threads -g^th of an inch in diam- 
eter, and of pale gray color ; and of small spores of round, 
oval flask, or dumb-bell shape, and of a pale greenish 
color. (Figs. 28, 29.) The spores gain access to the 

Fig. 28. 




Achorion Schoenleinii. (After Kaposi.) 



skin by the orifices of the hair follicles, and, after remain- 
ing there undisturbed, began to grow in the upper part of 
the hair sac, and between the superficial layers of the epi- 
dermis, and subsequently invade the hair, growing in its 
cortical substance. The cup may be formed either by the 
sinking in of the more central portion of the mass, or on 
account of the central portion being attached to the hair 
so firmly that it cannot so readily give way and bow out 
under the pressure of the growing fungus as do the parts 
further away from the hair. The atrophy of the skin is 



FAVUS. 



271 



largely clue to the pressure of the growing fungus, which 
is powerful enough to destroy the cranial bones of mice ; 
and in part to the inflammation of the skin produced by 
the presence of the fungus. 



Fig. 29. 




W 

A chorion Schoenleinii in hair shaft and follicle. (After Kaposi.) 

The question of the unity or non-unity of the fungus 
of favus is still unsettled. Several fungi, Quincke says 
three, and Unna asserts that there are nine, seem capable 
of producing the clinical picture of the disease. Other 
competent bacteriologists hold that the apparently diverse 



272 DISEASES OF THE SKIN. 

fungi are either different stages of development of the 
same fungus or due to different culture-media. All varie- 
ties of the achorion produce the same clinical picture. It 
is distinct from the trichophyton fungus. 

Diagnosis. Most cases of favus are easy of diagnosis : 
the sulphur-yellow cupped crusts ; the asbestos-like gray- 
ish masses ; the red, atrophic bald spots, with tufts of dry 
and more or less kinky hair in them ; and the peculiar 
odor being so well marked. Ringworm has none of these 
features. Moreover, it occurs in the form of circular, cir- 
cumscribed, only partially bald patches covered with gray- 
ish scales in moderate amount ; has characteristic nibbled- 
off " stumps " of hair ; and under the microscope we find 
the spores less abundant, smaller, and more uniformly 
round than in favus. It must be confessed, however, that 
without the clinical features of one or the other disease, 
none but a most expert microscopist could make the diag- 
nosis in a doubtful case by the microscope alone. In 
eczema baldness is very rare, and we will usually find a 
characteristic patch of the disease behind the ear ; its 
crusts are greenish and tenacious, not gray and friable ; 
the hair is matted by the sticky exudation ; and if dis- 
crete impetigo lesions are present, they will contain pus, 
and not be solid like the favus crust. Leaving the scalp 
alone for a time will decide the matter, as scutula will be 
sure to form if the disease is favus. Seborrhea causes a 
general thinning of the hair, the scalp is not atrophic, 
there are no scutula, and no achorion in the hair and scalp. 
Lupus erythematosus resembles favus only in producing 
atrophic red spots. There will usually be patches of the 
disease elsewhere, and its whole course is different. Pso- 
riasis does not cause atrophic bald spots, and rarely occurs 
on the scalp alone. Alopecia areata presents more or less 
circular bald areas, but these are white, smooth, and of 
normal texture, and there is no fungous growth in the 
hair. Alopecia from syphilis in its early stage resembles 
favus more closely than any other disease of the scalp ; 
but it occurs primarily at a later age than does favus, it 



FAVUS. 273 

comes on more suddenly, there is no history of crusts, and 
there will be other evidences of syphilis on the body, and 
(especially in women) the broken arch of the eyebrows. 

Treatment. In the treatment of the disease we need 
three weapons — patience, perseverance, and parasiticides. 
Before using the last we should always epilate, pulling the 
hair out systematically from clay to day so that eventually 
all the hair of the scalp is plucked. To do this we may 

Fig. 30. 




Piffard's epilating forceps. 

use the epilating forceps (Fig. 30); or Kaposi's method 
of grasping the hair between the thumb and a spatula or 
piece of stiff cardboard held firmly in the hand ; or, in 
dispensary practice, we may employ epilating sticks, made, 
according to Bulkier, of 

R . Ceree flava?, 3ij- 

Laccpe in tabulis, ^iv. 

Picis burgundicse, 5 X - 

Gummi damar., gJ 83 - M- 

These ingredients are to be melted together, and then 
moulded into sticks of a half-inch or more in diameter. 
They are to be used by melting the end, and when warm 
applying it to the hair with a sort of boring motion. 
When cold they are to be suddenly twisted oif, when, of 
course, they will bring many hairs with them. The 
" calotte/' or pitch-cap, used to be used for this purpose, 
but was given up because it caused the death of several 
patients. Kaposi's method is the best of all. If the head 
is greatly crusted, the crusts may be scraped oif with the 
curette or cleaned off by means of soaking the scalp with 
oil for a day or two, and then washing with soap and 
water. For an oil we can use sweet oil, sweet almond 
oil, or cotton-seed oil, with three per cent, of carbolic or 
18 



274 DISEASES OF THE SKIN. 

salicylic acid. The use of these oils should be continued 
throughout the whole course of the disease to prevent the 
spread of the fungus upon the scalp of the patient and to 
other people's scalps. After the first washing we should 
allow the scalp to go unwashed for several days at a time, 
so as to permit the full action of the parasiticide. 

After the cleansing and the epilation, the parasiticide 
must be rubbed and worked into the scalp. Of these 
there are many from which to choose. Sulphur ointment 
is one of the best, if properly and persistently used. 
Other ointments are thymol, naphthol, resorcin, and pyro- 
gallol in 5 to 10 per cent, strengths, and those of the 
ammoniate or yellow sulphate of mercury. Or solutions 
may be employed, as bichloride of mercury, two grains to 
the ounce of ether or alcohol ; the oleate of mercury or 
copper, 10 to 20 per cent.; tar; oil of cade; creosote in 
ether or alcohol ; sulphurous acid in full strength ; sali- 
cylic acid, five per cent, in oil ; or tincture of iodine. 
The latter, according to Sabouraud, should be used only 
once a month ; in the meantime the scalp should be washed 
alternately with alcohol and camphorated alcohol, or with 
a solution of salol, one and a-half per cent., and kept 
constantly anointed with iodine ointment. After a month 
the epilation and the iodine are to be repeated. Hydro- 
naphthol plaster does good service in favus, used accord- 
ing to the method described under Trichophytosis, which 
see. Peroni l recommends spraying the head with acetic 
acid used in an atomizer, after covering any excoriated 
points with diachylon ointment on a piece of cloth. At 
first the scalp feels cold. Hyperemia follows, which lasts 
about forty-eight hours and disappears, leaving slight des- 
quamation. When the hyperemia lessens, the acid is to 
be again used. When there are no excoriations the head 
is to be washed every morning and evening with water 
and corrosive sublimate soap. Busquet 2 recommends sop- 
ping on daily a solution of 

x Ann. de derm, et syph., 1891, ii., 797. 
2 Ibid., 1892, ii., 269. 



FAVUS. 275 

R . Essentia? cinnamomi, 10| 

Spts. aether, sulph., 30| M. 

Besnier and Doyon l recommend as a preparatory treat- 
ment for favus that the hair be cut off from and around 
all the patches, and the whole head then covered for two 
or three hours with equal parts of soft-soap and lard. 
This is to be washed off with warm water, and the head 
is to be kept covered during the night with a cap of rub- 
ber or other impermeable cloth. The next morning the 
head is to be washed perfectly clean, bathed with a solu- 
tion of boric acid (25 to 1000), and covered with borated 
lint soaked in the following solution : 



R . Sodii salicylati, 25 

Sodii bicarbonati, 10 

Aqua?, 1000 



M. 



Over all comes the impermeable cap. After a few days 
the dermatitis will disappear and the scalp will be clean, 
and then epilation must be practised, the hairs being 
pulled not only from the patches, but for about a half-inch 
about them. Epilation is to be repeated every week until 
no longer any trace of redness about the hairs exists, and 
the head is to be kept covered with the impermeable cap. 
Every evening the whole head is to be rubbed with an 
antiparasitic ointment such as : 

R. Bals. Peruv. vel 

01. cadini, 2 to 5 parts. 

Ac. salicyl., ) -- -, , K << 

-d • J ' > aa 1 to o 

Eesorcm, j 

Sulph. precip., 5 to 15 " 

Lanoliui, ^ 

Vaselini, y aa p. a?. ad 100 parts. 

Adepis, J M. 

Every morning the whole scalp is washed with tar 
soap, and each favic patch is soaked with the following : 

R . Alcoholis (90 per cent. ), 100 parts. 

Ac. acetic, (crystals), J to 1 part. 
Ac. boric. , 2 parts. 

Chloroformi, 5 " M. 

1 Kaposi. Mai. de la Peau. French ed., Paris, 1891. 



276 DISEASES OF THE SKIN. 

Then each patch is to be accurately covered with mer- 
curial plaster. 

Favus of the non-hairy parts of the body usually yields 
readily to the removal of the crust and the use of a para- 
siticide. 

Favus of the nail may be treated by the constant appli- 
cation of a mercurial, resorcin, or hydronaphthol plaster. 
If the disease is limited to one or two points, they may 
be cut down upon and the remedy applied directly. 
Sometimes it may be necessary to remove the whole nail. 

After a case of favus has been faithfully treated for a 
number of weeks and looks as if it were well, it should 
be let alone and watched carefully for a long time. Any 
red point that appears is evidence that the disease is crop- 
ping up again, and should be immediately attacked. 

Prognosis. The prognosis is good, provided the case 
is faithfully and energetically treated. Relapses will 
surely occur if any of the fungus remains in the scalp. 
A cure takes months or years to effect. The scars from 
favus are permanent. Favus of the nail is specially re- 
bellious to treatment, and may cause permanent destruc- 
tion to the nail. 

Feigned Eruptions. It is a good rule to consider the 
possibility of malingering whenever we meet with an 
eruption that does not correspond to any type eruption, 
and at the same time is not due to the action of drugs in- 
gested or locally applied, nor to irritants that have come 
accidentally in contact with the skin. Eruptions are 
feigned mainly by three classes of individuals, namely : 
Soldiers, sailors, or convicts for the purpose of shirking 
work ; paupers for the purpose of gaining admission to 
hospitals ; and hysterical young women for the purpose of 
exciting sympathy. Not only are feigned eruptions pecu- 
liar in appearance, but also it will be observed that they 
are usually on the left side of the body, as they are com- 
monly due to acids applied by the right hand ; or on the 
legs. The back is seldom the seat of these lesions. Most 



FIBROMA. 277 

commonly they are irritative lesions, such as would be clue 
to tartar emetic ointment, croton oil, nitric acid, carbolic 
acid, mustard, and the like. If made by acids, the lesions 
will often show lines radiating from the main mass show- 
ing where the acid has run further than intended. Some 
of the lesions imitate genuine disease with amazing clev- 
erness. 

It is impossible here to give a full account of the feigned 
eruptions. A good list is given by Van Harlingen, 1 and 
to this I would refer the reader. Sycosis by tartar emetic 
ointment and tar ; favus by means of acids ; alopecia are- 
ata by means of plucking the hair ; ringworm by means 
of depilatories ; scabies by means of excoriating with a 
fine needle ; various forms of ulcer and pustular eruptions 
by means of acids and caustics ; gangrene in the same way; 
all these and others have been simulated. 

Feuergiirtel. See Zoster. 

Feuermal. See Nsevus. 

Fever Sore. See Herpes facialis. 

Fibroma (Fi-bro'-ma 3 ). Synonyms : Fibroma mollus- 
ciun ; Molluscum fibrosum ; Molluscum simplex ; Mol- 
luscum pendulum. 

Fibromata are soft tumors of the skin that are com- 
posed of a hyperplasia of the connective tissue as well as 
the subcutaneous tissue, and occur in various shapes, 
colors, and sizes. The most commonly encountered form 
of fibroma is 

Molluscum fibrosum. These may be of the color of the 
skin, or pinkish, or even brownish or brownish-red ; most 
commonly they are of normal color. They may be 
rounded, flattened, sessile, or pedunculated, but always 
raised above the level of the skin. They may hang down 
like polypi. The skin over them feels soft and of normal 
texture, or it may be thickened or atrophied. A hair 

1 Morrow's System of Gen.-Urin. Dis., Sypli. and Dermat., vol. iii., 
N. Y., 1894. 



278 



DISEASES OF THE SKIN. 



sometimes grows from them. There may be but one or 
two present, or there may be hundreds of them so that 
the body is strewn over from head to foot with the vari- 
ously shaped tumors. The trunk is the most common 
location for fibromata, but they may occur on all parts 



Fig. 31. 




Multiple fibromata. 1 



and involve even the mucous membranes. (Fig. 31.) 
They give rise to no inconvenience except on account of 
their size, which sometimes may be that of a child's head 

1 From a photograph of a case of Br. E. T. Tappey, of Detroit. 



FIBROMA. 279 

or larger. Their usual size is from that of a cherry to 
that of a walnut. Many of them show a slow growth, 
while many are stationary, and some may involute. Com- 
edones of large size may accidentally form in some fibro- 
mata. The larger ones may ulcerate. All of them feel soft, 
while the larger ones may be elastic to the touch. When 
they hang down in the form of large skin-folds which 
have undergone hypertrophy, the term fibroma pendulum 
is applied to them. Dermatolysis (which see) has been 
considered as a form of fibroma. According to some au- 
thorities, fibrous moles and soft warts are but forms of 
fibroma. 

Etiology. Fibromata usually appear in childhood, 
though they may not do so until later in life. They are 
sometimes hereditary. They tend to increase with ad- 
vancing age — that is, they are not so large or numerous in 
children as in adults. Hebra taught that children with 
fibromata were stunted both physically and mentally, but 
this is not always true. By some authorities they are 
regarded as related to neuro-fibromata. 

Diagnosis. Molluscum fibroma differs from mottuscum 
contagiosum by not having a central depression, and by 
being of the normal color of the skin. They are also 
usually far more numerous. From fatty tumors they dif- 
fer in not being lobulated, and in being pedunculated, and 
less flat. Sebaceous cysts are not so numerous, and their 
contents can be squeezed out to a large extent, while fibro- 
mata are solid. 

There is another form of fibroma to which the name 
Acrochordon is applied. They occur as small, soft, pedun- 
culated, vascular, and mole-like lesions upon the face, 
shoulders, and elsewhere in elderly people whose skin is 
degenerated. They often take the form of little hernia- 
like sacs of skin when their contents have been absorbed. 

There is also a hard variety of fibromata called desmoids. 
These occur as round or oval compact smooth nodules, 
from hemp-seed- to pea-size. 

Treatment. They may be snipped off with scissors 



280 DISEASES OF THE SKIN. 

or tied off with ligature if pedunculated. If non-pedun- 
culated, they may be destroyed by electrolysis, or excised. 
If of large size, they must be excised. The galvano- 
cautery may be used to destroy any form. 

Fibroma Fungoides. See Mycosis fungoide. 

Fibroma Lipomatodes. See Xanthoma. 

Fibroma Molluscum. See Fibroma. 

Fibromyoma. See Myoma. 

Figwart. See Verruca. 

Filaria Sanguinis Hominis. See Elephantiasis. 

Filaria Medinensis. See Guinea-worm disease. 

Finnen. See Acne. 

Fischschuppenausschlag. See Ichthyosis. 

Fish-skin Disease. See Ichthyosis. 

Flachenkatarrh der Haut. See Eczema. 

Flachenkrebs. See Epithelioma. 

Fleckenmal. See Nsevus pigmentosum. 

Flechten. May mean Herpes, or (nassende) Eczema, 
or (fressende) Lupus. 

Flea-bites occur in the form of small red puncta which 
may or may not be in the center of wheals. They some- 
times bear a close resemblance to urticaria that has been 
scratched. The grouped arrangement of the lesions and 
the limited areas upon which they occur suggest their 
origin. 

Flesh Worms. See Comedo. 

Fluxus Sebaceus. See Seborrhoea. 

Folliculitis means an inflammation of the hair follicles. 
When the hairs involved are those of the beard we have 
F. barbce, or sycosis, which see. The hair follicles on the 
extremities, especially of the legs, may become inflamed 



FOLLICULITIS DECALVANS. 



281 



on account of some irritant applied to the skin. One 
form of this is tar acne. In workers in oil or paraffine it 
is no uncommon thing to see each hair on the legs, espe- 
cially the thighs, standing in the center of a red papule 
or pustule. The cure consists in removing the cause, in 
cleansing the parts, and the application of an alkaline 
soothing lotion. 

Folliculitis Decalvans. Under the name of folliculites 
et perifolliculites decalvantes agminees Brocq has described 

Flfr. 32. 




Folliculitis decalvans 



a form of inflammation of the hair follicle closely allied 
to sycosis. Besnier has given the same disease the name 
of alopecjcs cicatricielles innominees. It is characterized 
by an inflammatory process, which results in complete 



282 



DISEASES OF THE SKIN. 



destruction of the hair papillae, and the formation of 
cicatricial tissue ; and by a tendency for its lesions to ag- 
gregate themselves in groups. Besnier l reported a case 
of this in 1889. He says that it is the same thing that 
has been called acne" lupoide and folliculite epilante. In 
the case reported the disease affected all the posterior part 
of the scalp, which was sown over with disseminated 

Fig. 33. 




Folliculitis decalvans. 

patches of baldness of unequal size, irregular shape, and 
serpiginous. They were depressed in the center, which 
was smooth, polished, thinned, cicatricial, and completely 
bald. Their borders were not well defined, but merged 
into the islands of healthy hair. The scalp between the 
borders and the center of the patches was bald, of varie- 
gated redness, with some hairs broken off at the surface 
of the scalp. In the fuunel-shaped openings of the hair 
follicles there were little superficial collections of pus. 
Some of the patches were torn by scratching, and others 

1 Ann. de derm, et syph., 1889, x., 101. 



FOLLICULITIS DECALVANS. 283 

looked precisely like those of alopecia areata, without 
signs of inflammation. All treatment seemed to be in 
vain, and the scalp bore only the mildest applications. 

Another variety of folliculitis decalvans is that described 
by Quinquaud. It affects most often the scalp hair, more 
rarely that of the beard, pubes, and axillary region. It 
produces irregularly shaped areas of baldness, which are 
quite smooth, polished, pale, atrophic-looking, and pre- 
senting at some points slight redness. The areas are 
disseminated, about the shape of a franc-piece, separated 
by islands of healthy hair. The bald spots are slightly 
depressed. At the peripheries of the patches or in the 
islands of healthy hair between them will be found pin- 
head, discrete pustules about the hairs. The latter are 
easily plucked or fall spontaneously. Or we find simply 
punctiform, isolated, red spots which may or may not be 
scaly ; or a red, elevated, inflamed follicle. The fall of 
neighboring hairs produces the bald patches. The disease 
is very chronic and marked by a series of outbreaks. A 
micrococcus has been found in probable causative connec- 
tion with the disease. 

Still another form affects the bearded portion of the 
face and from there invades the temporal region of the 
scalp. This is the Ulerythema Sycosiforme of Unna, and 
the so-called chronic sycosis. It begins like a sycosis, 
but when the inflammation subsides it is seen that the 
skin is cicatricial and the hair destroyed. There may be 
one or more patches. The patches may be symmetrical 
or non-symmetrical, and they tend to spread slowly by 
peripheral extension. 

Treatment. The treatment found to be most effica- 
cious is to clean the scalp with soap and water ; to paint 
the diseased patches and their vicinage with the tincture 
of iodine ; and to bathe the same every morning with the 
following : 



Hydrarg. biniod. , 


S 1 '- j ; 


115 


Hydrarg. bichlor. , 


gr. iv ; 


1 


Alcohol. , 


gss; 


60 


Aquee destil., 


ad %iv ; 


500 f M. 



284 DISEASES OF THE SKIN. 

This will check the disease, but the baldness is irremedi- 
able. (Brocq.) 

Folliculitis Rubra. See Keratosis pilaris. 

Fragilitas Crinium. See Atrophia pilorum propria. 

Framboesia. See Yaws. 

Freckles. See Lentigo. 

Frieselausschlag". See Miliaria. 

Frostbite. See Dermatitis calorica. 

Fungous Foot of India. Synonyms : Madura foot ; 
Mycetoma ; Podelcoma ; Ulcus grave ; Tubercular dis- 
ease of the foot. 

This is a disease that is endemic in certain parts of India, 
but has been met with in this country. Though usually 
aifecting the foot and leg, it is seen occasionally on the 
hands, shoulders, and scrotum. According to Crocker, 
there are two varieties, the pale and the black, the latter 
being the more common. It may begin with slight con- 
gestion of the affected part ; or as a local induration, either 
superficial or deeply seated, of some part of the foot, which 
is firmer, larger, more diffused, and less painful than a 
boil. When this is opened it discharges pus at first, later 
granules like poppy seeds, or mulberry-like masses are 
mingled with the discharge. Or it may begin as a black- 
ish or bluish mottled discoloration like tatoo puncta. The 
progress of the disease is slow, but in the course of a few 
years the foot becomes swollen and distorted, the arch 
being broken, the toes being overextended, and the sole 
convex from behind forward. It becomes dotted over 
with the raised orifices of sinuses extending deep down 
into the tissues, and giving vent to the above-described 
discharge. 

It is more common in males than in females, and rare 
before puberty. Its origin is obscure, though it is supposed 
to be due to a fungus. Surgical interference is the only 
hope for a cure. 



FURZTNCULUS. 285 

Furunculus (Fii 2 -ruV-ku 2 l-u 3 s). Synonyms : (Fr.) Fur- 
oncle, Clou ; (Ger.) Blutschwar ; Furuncle or Boil. 

An acute circumscribed phlegmonous inflammation 
around a skin gland or follicle, characterized by one or 
more round, more or less acuminated/ firm, painful forma- 
tions, and usually terminating by necrosis and suppura- 
tion. (Foster.) 

Symptoms. This is a common and familiar disease of 
the skin. Its most frequent locations are the back of the 
neck, face, forearms, buttocks, and legs, though it may 
occur anywhere. It begins as a small, round, red, pain- 
ful spot, which, in two or three days, enlarges to attain 
the size of a split pea or silver quarter- or half-dollar. It 
is now raised above the surface, hard, of a dark-red color 
at the center with the redness fading away into the sound 
skin, more or less pyramidal in shape, exquisitely tender 
to the touch, and with a most agonizing throbbing pain. 
Its center soon becomes yellow, indicating the point at 
which suppuration has taken place, and where it will 
open. From the opening comes the "core," a greenish- 
gray or whitish pultaceous mass mixed with pus and 
blood. "With the escape of this, all the symptoms subside 
and the cavity fills up by granulation, leaving more or 
less of a scar. The course of the individual boil is from 
seven to ten or fifteen days. At times suppuration does 
not take place, but the mass undergoes resolution. This 
is the so-called " blind boil." 

There may be but one boil or there may be hundreds 
of them. They come out in crops of from two to half 
a dozen at a time. If very numerous, or of large size, 
they give rise to constitutional disturbance. They may 
continue to form for weeks, months, or even years, if left 
untreated. This is what is called furunculosis. 

Boils are always isolated. They may be confined to 
one spot or come out in a number of regions at the same 
time. There may be sympathetic enlargement of the 
neighboring lymphatic glands. If the disease is exten- 
sive, the patient presents a truly pitiable condition. 



286 DISEASES OF THE SKIN. 

If a boil starts from a sweat gland, it resembles that 
which originates in a sebaceous gland, except, according 
to Crocker, it has no mattery head and is somewhat less 
indurated. This form of boil is called " hydradenitis " 
by Verneuil and Bazin. It is of the size of a pea, and is 
most often met with in the axillae, about the anus and 
perineum, near the nipples, and may form anywhere where 
there are sweat glands, excepting on the soles of the feet. 

Boils may occur in the external auditory canal in con- 
junction with the disease elsewhere. They are exceed- 
ingly painful and produce deafness. One or both ears 
may be affected, but usually it is only one ear. They 
may set up inflammation of the entire canal and tym- 
panum ; one case of this sort has ended fatally. If the 
furuncle is situated in the posterior wall of the canal, or 
a general inflammation has been set up, considerable red- 
ness and tumefaction over the mastoid region may occur. 
(Dr. A. Rupp. 1 ) 

Etiology. The cause of furuncles is the entrance into 
the skin of the staphylococcus pyogenes aureus et albus. 
It would certainly seem that local infection does play a 
part in the production of crops of boils occurring in one 
region, and the doctrine of local infection finds further 
support in the results of treatment by antiseptics. It 
must be remembered that these micrococci are widely 
distributed, having been found in dishwater, in the super- 
ficial layers of decayed vegetable matter, in the swad- 
dling-clothes of healthy infants, in the dirt under the fin- 
ger-nails, and in numerous other places. Like other 
parasites, these require some peculiarity of soil for their 
growth, or at least an opportunity for gaining entrance to 
the glandular apparatus of the skin. The soil is afforded 
in lowered vitality of the skin, and thus we find boils in 
diabetes mellitus, after specific fevers, in anaemia, lithaemia, 
uraemia, and septicaemia ; and as a complication of other 
skin diseases, such as eczema, prurigo, lichen tropicus, and 
scabies. In many cases no disorder of the general health 

1 Personally communicated. 



FUEUNCULUS. 287 

can be discovered. The second condition is fulfilled by 
local injury to the skin, such as friction or pressure, or 
scratching. It is probable that they are contagious, as 
they are certainly auto-inoculable, and can be produced by 
inoculation of pure cultures of the micrococcus. The 
popular notion of their origin from too good living is only 
another way of saying that they occur in individuals not 
in perfect health. 

Pathology. The inflammation begins in the corium 
and deeper tissues in or about the hair follicles or glands 
of the skin. " The mechanism of the process is supposed 
bv some to be that the vessels around the gland or follicle 
become blocked, producing its death, and inflammation is 
then set up around the necrosed tissue to get rid of it by 
suppuration/' (Crocker.) 

Diagnosis. The disease is so common that there is no 
need for detailing the diagnosis. For the diagnosis from 
carbuncle, see under that word. 

Treatment. In many cases there is no need of in- 
ternal treatment. If the patient is out of health in any 
way, we should endeavor to help him back to his normal 
condition. In furunculosis we should always bear in mind 
the probability of there being diabetes mellitus at the bot- 
tom of the mischief, seek for it, and do our best to cure 
the patient if we find evidence of it. As a rule, tonics 
are called for. There are many drugs recommended for 
the treatment of boils, apart from constitutional condi- 
tions. Of these, sulphide of calcium is one of the most 
popular, one-tenth of a grain being given every two or 
three hours, or a fourth to a half-grain three or four times 
a day. It is of doubtful efficacy. Piffard speaks well 
of the compound syrup of the hypophosphites, a dessert- 
spoonful three times a day. Hardy recommends tar-water 
up to a quart a day. The sulphite or hyposulphite of 
sodium in fifteen- to twenty-grain doses three times a day 
is also well spoken of. Yeast is a homely but sometimes 
efficient remedy, either a half-wineglassful being taken 
night and morning, or a like quantity in divided doses, 



288 DISEASES OF THE SKIN. 

or one of Fleischmann's yeast cakes being eaten during 
the day. Le Gendre, 1 believing that boils may arise from 
the absorption of products of imperfect digestion, advises 
the disinfection of the intestinal tract by the use of the 
following powder : 



•1 



R. 0-Naphthol., 

Bismuth, salicylate j- aa gr. ivss; 

Magnesia carb. 



30 
M. 



which is to be given every four hours. 

The local treatment of boils is important and efficient. 
They should not be poulticed, as, being due to a fungus, 
the heat and moisture only facilitate the growth of the 
same and the production of new boils. That new boils 
are apt to spring up about a poulticed boil is a common 
experience. " Hands off" is the rule for young boils, nor 
should old ones be squeezed. We should endeavor to abort 
the development of a boil. To do this there are various 
approved methods, but the one most highly commended is 
the use of carbolic acid. This may be either by touching 
them with pure carbolic acid ; injecting them with a few 
drops of a two per cent, solution ; or spraying them with 
the same solution for fifteen minutes at a time eight times 
during the day, and keeping them covered with carbolized 
dressings in the meantime. Mercury may be used instead 
of carbolic acid, the boil being kept covered with emplas- 
trum hydrarg. with a little hole cut in the plaster to cor- 
respond to the center of the boil ; or an ointment of the 
nitrate or red oxide may be used. Painting with iodine 
is also commended ; as well as keeping them covered with 
a saturated solution of boric acid, or an eight or ten per 
cent, plaster or ointment of salicylic acid. Hardaway 
speaks highly of Unna's carbolic acid and mercury mull 
plaster. Electrolysis to destroy the follicle is spoken of 
by the same authority. 

When aborting is out of the question, it is a good plan 
to thrust a little pure carbolic acid, on the sharpened end 

1 Union Med., 1888, xlv., 98. 



FURUNCULUS. 289 

of a wooden toothpick or the like, into the central open- 
ing. It hurts for a few minutes only, and is promptly 
curative. The boil should then be dressed with carbolizecl 
vaseline or a boric acid ointment. Or it may be opened 
and dressed with iodoform, or aristol, as the odor of the 
former is objectionable. Here too the mull plaster of car- 
bolic acid and mercury may be used. Instead of the pure 
carbolic acid, Crocker advises the glycerole of carbolic 
acid of the British Pharmacopoeia. 

Furuncles of the ear. My friend, Dr. A. Rupp, late 
aural surgeon to the New York Eye and Ear Infirmary, 
has kindly advised me on this head as follows : If the 
auditory canal be filled or unclean, it must be syringed 
out with a two to five per cent, solution of carbolic acid 
followed by a solution of bicarbonate of soda as hot as 
can be comfortably borne. 

The canal is to be dried with absorbent cotton, and if 
the membrana tympani is intact filled with 



R. Hydrarg. bichlor., gr. 

Glycerin!, \ r „ ^ . 



Alcoholis 






M. 



which is to remain in some minutes, and then the excess 
is allowed to drain off. The canal is lightly closed with 
borated or salicylated absorbent cotton. If the mem- 
brana tympani is deficient, the whole canal is to be filled 
with powdered boric acid, and the orifice closed as before. 
In either case the cotton is to be changed when soiled. 
When furuncles are at the inner end of the canal near the 
membrana tympani, a leech or two in front and a little 
above the tragus will afford much relief. It is unneces- 
sary to incise the furuncles except where pus has formed 
and has no outlet. 

Peognosis. In most cases boils are annoying, but not 
dangerous. Those about the face give the most trouble. 
How long new boils will continue to form it is impossible 
to say. All will depend upon how soon we can get the 
patient into a better physical condition. 
19 



290 DISEASES OF THE SKIN. 

Furunculus Orientalis. See Aleppo boil. 

Gale. See Scabies. 

Gangrene of the Skin. See Dermatitis gangrenosa. 

Gansehaut. See Cutis anserina. 

Gefassmal. See Nsevus vasculosns. 

German Measles. See Rubeola. 

Geromorphisme Cutane is the name chosen by Drs. 
Souques and Charcot 1 to designate an affection that pro- 
duced changes in the skin of a girl eleven years of age so 
that she looked like an old woman. The expression of 
the face suggested that due to facial paralysis. The skin 
hung in loose folds, and was flabby like the skin some- 
times seen in very old people. Apart from loss of natural 
consistence and elasticity there was no change in the skin. 
If lifted up, twisted, or folded in any way, it returned 
very slowly to its normal position ; and it was abnormally 
movable over the subcutaneous tissues, in these things 
suggesting that form of dermatolysis called " elastic skin." 
There were no changes in the hair, nails, or teeth. There 
was no assignable cause for the condition, which was pre- 
served unaltered during an interval of ten years from the 
first to the last time that the doctors saw the case. 

Geschwiire. See Ulcers. 

Gesichtsatrophie. See Atrophoderma idiopathica. 
Glanders. See Equinia. 
Glanzhaut. See Atrophoderma idiopathica. 
Glossy Skin. See Atrophoderma idiopathica. 
Gneis. See Seborrhoea sicca. 
Gommes Scrofuleuses. See Scrofuloderma. 
Goose-flesh. See Cutis anserina. 

Granulationsgeschwulste (Ger.). Connective-tissue new 
growths. 

1 Nouvelle Iconographie de la Salpetriere. 



G UINEA- WORM DISEASE. 291 

Granuloma (Gra 2 n-u 2 l-o v -ma 3 ). This is a tumor con- 
sisting of granulation tissue. "Proud flesh " is of this 
nature. It is seen about wounds, such as that caused by 
vaccination. It is probable that there is some specific 
germ to cause the growth of these exuberant granulations. 
It sometimes takes the form of a raspberry. The appli- 
cation of nitrate of silver or tincture of iodine to it will 
cause it to flatten down speedily. 

Granuloma Fungoides. See Mycosis fungoi'des. 

Grayness. See Canities. 

Greisenhaftigheit der Kinder. See Sclerema neonato- 
rum. 

Grocer's Itch is eczema of the hand. 

Grubs. See Comedo. 

Grutum. See Milium. 

Grutzgeschwulst. See Atheroma. 

Guinea-worm Disease or Dracontiasis is met with en- 
demically in tropical climates. It is caused by the larvae 
of the guinea-worm, or filaria medinensis, being swal- 
lowed, and developing in the body. The female makes its 
way into the muscles, and within nine or twelve months 
gives rise to the symptoms of the disease. The male prob- 
ably dies and is passed out of the body. The symptoms 
of the disease are a small tumor under the skin that feels 
like a coil of soft string ; the appearance of a pea- to fil- 
bert-sized vesicle upon this when the animal is about to 
escape ; tension, pain, and itching ; in severe cases in- 
flammation, purulent discharge, hectic fever, and perhaps 
delirium. The worm is either gradually wholly extruded 
after the vesicle breaks, or a new tumor forms after a 
part has escaped, and this after a time breaks and the rest 
of the worm comes away. There may be only one worm 
or a legion of them. They are located most often in the 
foot, but may be found anywhere. 

Treatment. The treatment of' the disease is to re- 



292 DISEASES OF THE SKIN. 

move the worm, which is done by winding it carefully 
around a stick when the head is protruded, giving a turn 
or two every day until the Avorm is extracted. Manson 
advises against this, and speaks well of injecting into the 
tumors a 1 to 1000 solution of bichloride of mercury. 
This kills the worm, and it can then be removed. Tinc- 
ture of asafoetida in doses of one or two drachms three 
times a day kills the worm before extraction. 

Gumma. See Syphilis. 

Gune. See Tinea imbricata. 

Gurtelkrankheit. See Zoster. 

Gutta Rosea. See Rosacea. 

Haarmenschen. See Hypertrichosis. 

Hsematidrosis (He 2 m-a 2 t-i 2 -dro r -si 2 s) or Haemidrosis 
(He 2 m-i 2 -dro r -si 2 s) is a rare disease of the sweat glands in 
which, on account of an effusion of blood into the coils 
and their ducts by diapedesis from the surrounding vas- 
cular plexus, blood is discharged upon the skin along with 
the sweat. The subjects are apt to be hysterical young 
women, though the affection has been seen in newborn 
children. It is in some cases vicarious menstruation. 
The points of election are the face, ear, umbilicus, hands, 
and feet, Ephidrosis cruenta and bleeding stigmata are 
other names for the curious malady. The treatment 
should be directed to the condition of the individual. 

Hsemorrhcea Petechialis. See Purpura. 

Hair, Discolorations of. Hair sometimes falls out to 
grow in of a different color. The continuous hypodermatic 
administration of pilocarpine has been followed by a change 
of color of the hair from light to dark. Green hair occurs 
in workers in copper ; blue hair occurs in workers in 
cobalt and indigo. These colors can be removed by wash- 
ing. Yellow hair is occasionally seen in icterus. Various 
chemicals bleach the hair, such as peroxide of hydrogen. 



HERPES. 293 

Chrvsarobin stains it purple ; resorcin may stain it green. 
Bicarbonate of soda changes dark hair to a dirty brown. 

Harlequin Foetus. See Ichthyosis congenita. 

Hautfinne. See Acne. 

Hauthorn. See Cornu cutanemn. 

Hautgries. See Milium. 

Hautkrebs. See Epithelioma. 

Hautsclerem. See Scleroderma. 

Haemorrhage Cutaneous. See Purpura. 

Haematrophia Facialis. See Atrophoderma idiopathica. 

Henoch's Disease. See Purpura fulminans. 

Herpes (Hu 5 r-pez). An acute inflammatory disease of 
the skin characterized by an eruption of one or more 
groups of vesicles upon reddened bases. 

There are two main varieties of the disease : one occur- 
ring upon the face, herpes facialis and one occurring upon 
the genitals, herpes progenitalis. 

Symptoms. Herpes facialis, also called herpes febrilis, 
herpes labialis, hydroa febrilis, fever blister or cold sore, 
usually occurs upon the lower part of the face, about the 
mouth (Fig. 34). There is commonly some slight dis- 
turbance of the general economy, not as part of the dis- 
ease, but as the cause of it. The patient first notices 
more or less marked burning, stinging, or itching in the 
part, and perhaps at the same time erythematous papules 
may form. After a few hours a number of pinhead- to 
pea-sized, clear, fully distended vesicles will appear upon 
an erythematous base. Perhaps the herpetic patch may 
appear suddenly without antecedent erythema. There is 
usually not more than one or two patches of small size. 
There may be a score or more of them, and they may be 
of large size. The patches are always irregular in shape. 
There may be but two or three vesicles in a group, or 
there may be a dozen of them. They do not tend to 



294 DISEASES OF THE SKIN. 

break down of themselves, but after a few days dry up 
into a crust which falls and leaves a red spot that soon 
disappears. Sometimes the vesicles may coalesce into 
bullae, the covers of which may fall and a superficial ul- 
ceration be left. The duration of the disease is about 
eight or ten days. The most common location is upon 

Fig. 34. 




— - 



■^0 




Herpes febrilis. 

the upper lip, but it may be anywhere upon the face, and 
not uncommonly the groups develop bilaterally. The 
mucous membrane of the mouth may also be involved, 
but here, owing to the heat and moisture, the vesicles are 
seldom seen, as they break down and leave excoriated 
points. There is a strong tendency for the disease to 
recur with the recurrence of the exciting cause. In some 



HERPES. 295 

cases it recurs at irregular intervals for months and with- 
out apparent cause. 

Etiology. It is still an undetermined question whether 
herpes facialis is a zoster or not. By most authorities it 
is considered to be an independent disease ; by a few it is 
thought to be an incomplete zoster. It is known to occur 
with catarrhal inflammations of mucous membranes, such 
as a coryza or bronchitis ; with digestive derangement, as 
gastritis or enteritis ; with various febrile diseases ; and 
it is very often seen in women as a herald of the menstrual 
epoch, occurring with great regularity for years. It arises 
sometimes on account of an injury to the terminal ends of 
the nerves, and, as such injuries are liable to occur in the 
tender mucous membrane of the lips, this may be an ex- 
planation of its frequency about the mouth. Infection has 
been invoked by a few observers as a cause, but this is 
not proven. It is evidently a neurosis. Sometimes it 
occurs coincidently with herpes progenitalis, or with zoster. 

Diagnosis. It must be diagnosticated from zoster and 
from vesicular eczema. From zoster it differs in not oc- 
curring in a series of groups scattered along the course of 
distribution of the trigeminus ; and in frequently being 
bilateral. Generally speaking, there is more marked 
neuralgia in zoster, though in some cases this is wanting. 
From eczema it differs in the large size of its vesicles, in 
their showing no tendency to break down, in being less 
pruriginous, in running a regular course and rapidly re- 
covering by the simple drying up of the vesicles. 

Treatment . Left to itself, the disease will speedily 
get well, and really requires no treatment beyond protec- 
tion with flexible collodion, or any indifferent soothing 
lotion or ointment. \Ve are often asked if we cannot 
prevent or abort the disease when due to the menstrual 
flux. \Yomen know well that the application of spirits 
of camphor will sometimes do this. Hardaway recom- 
mends rubbing the part with borax. Or one of the alco- 
holic solutions recommended by Leloir for this purpose in 
herpes progenitalis may be used, namely, either 2 per cent. 



296 DISEASES OF THE SKIN. 

resorcin ; 1 per cent, thymol ; 3 per cent, menthol, or 2 
per cent, tannin frequently applied. 

Herpes progenitalis. This has been called herpes pre- 
putialis, but as it occurs in women as well as men and on 
other places than the prepuce, that name is obviously in- 
correct. 

Symptoms. The eruption is preceded and accompanied 
by burning and itching, and the vesicles occur in groups 
upon an erythematous base. If on the prepuce, that part 
is sometimes swollen. The vesicles are at first clear with 
serous contents, and if on moist locations, as under the 
prepuce or about the mucous membranes of the female 
genitals, they soon break down and leave tiny excoria- 
tions. There may be but one or several patches of herpes. 
The disease runs a course of eight or ten days and gets 
well of itself, unless irritated under the mistaken idea of 
its being a chancroid. 

According to Bergh, 1 who has made a careful study of 
the disease, in women the groups usually contain five to 
eight pinhead- to hemp-seed-size vesicles, but may have 
twenty to thirty-five millet- to poppy-seed-size vesicles. 
Around each group is a reddish areola. The vesicles are 
isolated, and seldom confluent. Itching is apt to precede 
their outbreak. There may also be slight tenderness or 
swelling of the neighboring glands. In both sexes the 
patches may be unilateral, bilateral, or median. In men 
it occurs most frequently on the inner surface of the pre- 
puce, then on its outer surface, the sulcus, glans, meatus, 
sheath of the penis, and rarely in the meatus. In women, 
Bergh found it most often on the labia majora, then the 
labia minora, and anogenital region ; seldom on the clitoris 
or in the vestibule ; very rarely on the cervix uteri. 
Unna 2 gives the order of frequency as labia minora, 
clitoris, labia majora, introitus vagina? et carunculse myrti- 
formes, perineum, anal region, genito-crural fold, mons 
veneris, and mucous membrane of anus and vagina. The 

1 Monatshefte f. prakt. Dermat., 1890, x., 1. 

2 Journ. Cutan. and Ven. Dis., 1883-4, i., 321. 



MERPES. 297 

disease lias a tendency to relapse, in men with each coitus, 
in women with each menstrual period. It is very com- 
mon in women to have herpes of the face at the same 
time, and this has been noted in men. 

Etiology. The cause of the disease is congestion of 
the genital region. Thus in men it is frequently seen two 
or three days after each coitus ; or accompanying a gonor- 
rhoea or chancre (soft sore). A long prepuce seems to 
predispose to it. In women it comes in 80 per cent, of 
the cases with menstruation (Bergh), and in them it does 
not seem to have any marked relation to the sexual act. 
It is also seen in connection with pregnancy and the puer- 
peral state. It is a not infrequent disease. Greenough 1 
met with it in men in about 1 7 per cent, of all venereal 
cases in private practice. In women there are no statis- 
tics from private practice, and, indeed, it is in this country 
but rarely reported. Both Bergh and Unna, however, 
met with it very frequently in public prostitutes in St. 
Petersburg and Hamburg. 

Diagnosis. The disease of itself is of little moment, 
but is of great consequence viewed from a diagnostic stand- 
point on account of its liability to be taken for chancre 
(soft sore), or for the initial lesion of syphilis. This can 
hardly occur if the vesicles are seen, but when they are no 
longer present some difficulty may arise. From chancre 
the superficial character of the lesion points toward herpes. 
In case of doubt the use of a simple dusting powder for a 
day or two will clear up the difficulty, because the chancre 
will continue to enlarge while the herpes will become well. 
Auto-inoculation will afford positive evidence. From the 
initial lesion of syphilis herpes differs in the absence of all 
induration of its base, and in the inflammatory character 
of the lesion. Here again a short wait will clear up the 
diagnosis. 

Tbeatmext. Herpes progenitalis will usually promptly 
disappear by the use of a dusting powder of bismuth, or 
oxide of zinc and starch ; or by covering it with a piece of 



298 DISEASES OF THE SKIN. 

lint soaked in an astringent solution, such as a weak lotion 
of liquor plumbi subacetatis. If suppuration has occurred 
on account of bad treatment, and the glands are enlarged 
or tender, the patient had best be put in bed. Circum- 
cision has been recommended to prevent recurrences, but 
is of doubtful efficacy. It is well to have the patient wash 
the parts daily, and after coitus. Marriage and fidelity to 
the wife are good means of curing a relapsing herpes. 
Astringent washes are useful in both sexes. If the 
" habit " of herpes progenitalis, as it may be termed, has 
been formed, careful hygienic and general treatment may 
be necessary for a cure. Leloir's directions, as given 
under herpes facialis, may be tried for aborting the disease. 

Herpes Circinatus is either erythema iris or trichophy- 
tosis corporis. 

Herpes Circinatus Bullosus was the name given by 
Wilson to what has since been called Herpes gestationis. 

Herpes Cretace. See Lupus erythematosus. 

Herpes Esthiomenes. See Lupus vulgaris. 

Herpes Gestationis is regarded as being a dermatitis 
herpetiformis occurring during and provoked by preg- 
nancy. It is prone to relapse with each succeeding preg- 
nancy ; and slowly subsides after delivery. Apart from 
its etiological relation, it corresponds closely to dermatitis 
herpetiformis, which see. 

Herpes Imbrique. See Trichophytosis corporis. 

Herpes Iris. See Erythema Iris. 

Herpes Parasitaires. See Trichophytosis corporis. 

Herpes Phlyctaenoides. See Zoster. 

Herpes Tonsurans, seu Tonsurant. See Trichophytosis 
capitis. 

Herpes Tonsurans Muculosus. See Pityriasis rosea. 



HIDROCYSTOMA. 299 

Herpes Zoster. See Zoster. 

Herpetide Maligne Exfoliative. See Dermatitis ex- 
foliativa. 

Herpetide (E 2 r-pa-tecl). This is a class of skin disease 
which depends upon what the French writers call the her- 
petic diathesis. The affections in this class are marked 
by long duration ; obstinacy to treatment ; tendency to 
relapse ; and more or less pain and discomfort. Under it 
are included eczema, the lichens, psoriasis, and prurigo. 

Hidrocystoma (Hi-dro'-sist-o'-rua 3 ). This disease was 
formerly regarded as a pompholyx of the face, but Robin- 
son * has shown that it is a separate affection. 

Symptoms. The eruption occurs upon the face in the 
form of a large number of discrete, disseminated, tense, 
clear, watery, boiled sago-grain-like vesicles. In size 
they vary from that of a pinhead to that of a pea. In 
color they may be light yellow, of a bluish tint, or white. 
If pricked, a drop of clear acid fluid escapes. They are 
obtuse, round, or ovoid. If they are present in immense 
numbers, they may crowd closely together, but do not 
coalesce. There is no sign of inflammation about them, 
and no subjective symptoms arise from them, excepting, 
at thnes, a feeling of tension or smarting that is not pro- 
nounced. After lasting several weeks they dry up and 
disappear, while new ones appear. 

The eruption is usually seen upon the lower part of the 
forehead, the orbital region, nose, cheeks, lips, and chin, 
that is, upon the middle regions of the face. 

Etiology. Most cases occur in women, and especially 
in washerwomen. It is worse in summer, often disap- 
pearing entirely in winter, to return in the following sum- 
mer. It is a disease of adult life. 

Pathology. The secreting portion of some of the 

sweat glands have an enlarged lumen from dilatation of 

the tube and contraction or compression of the epithelial 

cells against the basement-membrane, the lumen being 

1 Journ. Cutan. and Gen.-Urin. Dis/, 1893, xi., 293. 



300 



DISEASES OF THE SKIN. 



filled with liquid, and a granular material resembling that 
usually seen in normal glands, but in increased amount. 
With the exceptions of those thus affected, the excretory 
apparatus was normal. (Robinson.) 



Fig. 35. 








Hidrocystoma. 

Treatment. As far as possible the patient must avoid 
everything that will cause sweating. The individual 
lesions must be punctured. 

Hirsuties. See Hypertrichosis. 

Hives. See Urticaria. 



HYDRO A VACCINIFORME. 301 

Homines Pilosi. See Hypertrichosis. 

Homines Sylvestris. See Hypertrichosis. 

Honeycomb Ringworm. See Favus. 

Horn. See Cornu cutaueurn. 

Hiihnerauge. See Clavus. 

Hyalome Cutane. See Colloid degeneration of the 
skin. 

Hydradenitis suppurativa. See Furuncnlus of sweat 
glands. 

Hydradenomes Eruptifs. See Adenoma of sweat glands. 

Hydroa (Hi-dro'-a 3 ) is practically dermatitis herpeti- 
formis. It is an old term recently revived, and is of un- 
certain significance. By some it is used to designate 
eruptions that are midway between erythema multiforme 
and pemphigus. As dermatitis herpetiformis certainly 
comprises what has been described as hydroa ; I shall con- 
sider the latter no further. 

Hydroa Bulleux. See Erythema iris. 

Hydroa Vacciniforme. Hutchinson, under the name of 
" Recurrent Summer Eruption," Unna, under the name of 
" Hydroa Puerorum," and Bazin, under the name at the 
heacl of this section, have described a bullous disease that 
occurs mostly in boys and upon exposed parts. It usu- 
ally occurs in summer and then seems to be due to the heat 
of the sun. It may occur in winter and be due to the 
action of high winds. The bullae form as such or as the 
result of the confluence of vesicles, and commonly both 
vesicles and bullae are present at the same time. The 
vesicles are prone to become depressed in the center and 
resemble vaccine scars. Scarring is apt to result. The 
disease recurs from time to time and tends to cease alto- 
gether as puberty is reached. The disease is related clini- 
cally to bullous erythema and to dermatitis herpetiformis, 



302 DISEASES OF THE SKIN. 

though it differs from them in leaving scars. Bowen has 
shown that it is inflammatory in origin. 

Hygroma Cysticum Colli Congenitum. See Lymphan- 
gioma. 

Hyperesthesia (Hip-u 5 r-e 2 s-the r -zi 2 -a 3 ). This is that 
condition of the skin in which pain is experienced on the 
slightest contact even of a current of air, in this differing 
from dermatalgia, in which the pain is spontaneous. It 
is a neurotic disease and is met with most commonly as a 
symptom of other diseases, such as non-tubercular lep- 
rosy, hydrophobia, and hysteria. Idiopathic cases are met 
with, though rarely. The hyperesthesia may be general 
or localized, unilateral or symmetrical. 

The treatment is in most cases that of the disease of 
which it is but a symptom. Barbillion 1 cured one case of 
the idiopathic variety by blisters, and two cases by conge- 
lation by means of methyl chloride. It is probable that 
cataphoresis by cocaine after the method of Peterson might 
be beneficial. This is done by means of disks of filter- 
paper soaked in cocaine, and placed on a specially made 
electrode attached to the positive pole of a galvanic bat- 
tery. The sponge electrode attached to the negative pole 
is placed indifferently on the skin, and a current of some 
five milliamperes, if the patient can bear so much, is allowed 
to pass for fifteen or twenty minutes. 

Hyperidrosis (Hip-u 5 r-i 2 d-ro r -si 2 s). Synonyms : Ephi- 
drosis ; Idrosis ; Sudatoria ; Polyidrosis ; Excessive Sweat- 
ing. 

A functional disorder of the sweat glands characterized 
by an excessive flow of sweat. 

Symptoms. Hyperidrosis may be general or localized ; 
unilateral or symmetrical ; in large or small amount. The 
cases of general sweating occur most often symptomatically 
in the course of general diseases, such as phthisis, malaria, 
and rheumatism, and do not concern us now. Some cases 

iProgres Med., 1885, i., 375. 



HYPEBIDROSIS. 303 

occur idiopathically. Such patients are usually fat. The 
hyperidrosis may be constant or at intervals, beiug excited 
by the slightest irritation of the nervous system, or by 
muscular exertion. The outburst of the sweat is generally 
preceded by a prickling sensation. It is apt to be accom- 
panied by prickly heat (lichen tropicus). 

We are called upon as dermatologists to treat localized 
sweating more often than the just-described variety, and 
such cases occur most commonly upon the palms and soles, 
in the axillae, about the genitals, and on the face and scalp. 
The excessive flow of sweat may be constant, but it is 
usually paroxysmal, and often under the influence of the 
emotions. It is usually more pronounced in warm than 
in cold weather. Fat people are more prone to it than 
are those Avho are thin ; anaemic and delicate people rather 
than the robust. In some cases there may be a sense of 
tingling before the flow occurs. The affected part may be 
warm or cold ; if the first, it is apt to be somewhat hyper- 
emia Occurring in places that are warm and covered, 
bromidrosis is a common accompaniment. The disease 
may last for years. 

Sweating palms usually feel cold and clammy. Some- 
times the amount of sweat is only enough to keep them 
more or less constantly moist ; sometimes it is so abundant 
as to drop from the hands and fingers, or even to fill up 
the upturned palm and run over the edge. It spoils 
gloves, and interferes with many forms of work. Sweat- 
ing soles are soon followed by tender feet, the epidermis 
becoming sodden, macerated, and removed. It interferes 
with walking. The edge of the foot just about the soles 
appears as a white or gray line or seam of sodden epi- 
dermis with a pinkish seam above it. The sodden appear- 
ance is also well marked between the toes. Sweating in 
the axilhe spoils the clothing, and is only rendered worse 
by the rubber dress-shields so commonly worn by women. 
In its paroxysmal form it is frequently encountered in 
patients stripped for examination in public. This form 
has been aptly named by the French the " military sweat," 



304 DISEASES OF THE SKIN. 

as it is seen so often in examining recruits for the army. 
Sweating about the genitals is often accompanied by in- 
tertrigo, which may also occur in other parts subject to 
hyperidrosis where folds of skin are in contact. Sweating 
of the face is most commonly encountered upon the fore- 
head, nose, and eyelids, beads of sweat standing out upon 
them or running off in little rivulets. It is here that 
hsemiclrosis is most common. Upon the scalp it has been 
observed that its occurrence is frequently followed by loss 
of hair. 

Unilateral sweating is occasionally met with. It may 
affect half of the forehead or face, or whole body. Upon 
the forehead and face this form of sweating occurs as an 
accompaniment of migraine and limited to the painful re- 
gion ; it is in paraplegia that one-half of the body alone is 
affected. 

Etiology. The disease is probably due to a disturb- 
ance in the sphere of the sympathetic system. It has 
followed lesions of the cerebro-spinal nerves. It occurs 
in all classes and conditions of men, and in all ages and 
both sexes. In some cases it is hereditary. Ill health 
seems to be the cause in many cases ; it may be anaemia ; 
chlorosis ; lithsemia ; hysteria ; or general debility. In 
any case it is purely a functional disease of the sweat glands, 
they being structurally ud changed. 

The diagnosis is so evident that we need not stop to 
differentiate it systematically. 

Treatment. The condition of the patient's health is 
to be carefully investigated, and tonics, mineral acids, nux 
vomica, or other medicine ordered according to the nature 
of the case. If there is no indication for this plan, or it 
does not succeed, recourse may be had to belladonna or 
atropia to the point of producing their full physiological 
effect ; or pilocarpine ^L gr. t. i. d.; or agaricin in dose of 
^ gr.; or ergot half a drachm of the fluid extract t. i. d. 
Crocker has found a rail teaspoon of precipitated sulphur 
in milk twice a day the best remedy. If it loosens the 
bowels too much, he prescribes it as follows ; 



HYPERTRICHOSIS. 305 

R. Pulv. cretae co., ojij; 25 | 

Pulv. cinnam. co., 5ij> 15 

Sulph. prsecip., gj; 100| M. 

Sig. A teaspoonful twice a day. 

The local treatment in many cases is as unsatisfactory 
as the constitutional treatment. There have been many 
plans proposed. Local faradization is one agent. Very 
hot water may be sponged on for a few minutes ; bella- 
donna ointment or liniment may be rubbed in ; or we 
may use some astringent application, as of bismuth, tan- 
nin, alum, sulphate of zinc, borax, and the like, in alco- 
hol, ointment, or powder. As a rule ointments cannot be 
used on the hands and face. The most reliable of these 
is probably a saturated solution of boric acid, or a 3 per 
cent, solution of salicylic acid. Kaposi speaks highly of 
the good effect of bathing the parts with a 5 per cent, so- 
lution of naphthol in alcohol, and keeping them powdered 
with one part of naphthol to one hundred of starch. Pif- 
fard recommends freshly prepared silicic hydrate, one 
part, in ointment of rose-water, nine parts. Sulphate of 
quinine, 5 per cent, in alcohol, may be tried. For sweat- 
ing of the feet the best means are those given under Bro- 
midrosis, which see. Permanganate of potash in 1 per 
cent, strength may be used. Unna recommends ichthyol 
in 2 J per cent, ointment and the use of ichthyol soap. 
Formalin has its advocates. P. Bichter l advises sprink- 
ling tartaric acid between the toes and in the stockings for 
sweating of the feet ; and painting with a 10 per cent, 
solution of chromic acid every five days for sweating of 
the hands. 

The prognosis is doubtful, many cases proving very 
rebellious to treatment. 

Hyperkeratosis excentrica. See Porokeratosis. 

Hypertrichosis (Hip-e 2 r-trik-ho'-si 2 s). Synonyms : Hir- 
suties ; Trichauxis ; Polytrichia ; Dasyma ; Trichosis hir- 
suties ; (Fr.) Poils accidentels ; Superfluous hair. 

1 AUg. Med. Centr. Zeit., 1897, lxvi., 927. 
20 



306 DISEASES OF THE SKIN. 

Symptoms. Hypertrichosis is a growth of hair that is 
either abnormal in amount or occurs in places where, nor- 
mally, only lanugo hairs are present. It may be general 
or partial, congenital or acquired. The general form is 
also congenital, but it is never universal, as no hair grows 
upon the palms and soles, the backs of the last phalanges 
of the fingers and toes, the inside of the labia majora, the 
prepuce, and glans penis. Subjects of this malady are 
usually born covered more or less thickly with hair, which 
may be light or dark in color. This continues growing 
longer, coarser, and darker till it reaches its full develop- 
ment. As a rule, the long hair covering the body is fine, 
resembling more the hair of the head than of the beard, 
as is also the case with the hair on the face of these people. 
With this excessive growth of hair there is usually com- 
bined a deficiency of teeth, specially marked in the upper 
jaw. Subjects of this malady are called homines pilosi 
and are met with in all quarters of the Avorld. 

Of partial congenital hypertrichosis we have an immense 
number of examples. This condition is apt to be of the 
nature of nsevus. The distinction between a localized 
hypertrichosis and a nsevus is made mostly upon the color 
of the underlying skin. In the former case the skin is 
perfectly normal, while in the latter it is jnguiented and 
may be otherwise altered. These localized and partial 
cases of hypertrichosis are most frequently met with in 
the sacral or lumbar region, and not infrequently are asso- 
ciated with spina bifida. 

Partial acquired hypertrichosis is more common than is 
the congenital variety, and takes the form either of an ex- 
cessive growth of hair in regions where it is usually found, 
or of the development of hair in regions usually hairless or 
only provided with downy or lanugo hair, or of the devel- 
opment of pubertal hair at an early age. 

The following cases are instances of excessive growth 
and precocious development. Chowne l speaks of a boy, 

1 Lancet, 1852, i., 421. 



HYPERTRICHOSIS. 307 

eight years of age, who had the whiskers of a man. Beigel l 
has seen a six-year-old girl with pudenda like a twenty- 
year-old woman, both in shape and hair. A case of 
excessive growth was met with by Leonard 2 in a man in 
his neighborhood whose beard measured seven feet six and 
a half inches in length. Other instances of excessive 
length of beard are found in medical literature. 3 Many 
men have an excess of hair upon the chest and shoulders. 
Hair is generally better developed upon the forearm than 
upon the upper arm, and upon the legs than upon the 
thighs. As men grow old they are apt to have long hairs 
grow from the nostrils and the ears. These are instances 
of the' growth of strong hair where normally only lanugo 
hairs are present. 

The growth of the beard in women is the form of hyper- 
trichosis which concerns us most, as it is the deformity 
which we will be called upon to cure. As women grow 
old, especially after they have passed through the climac- 
teric period of middle life, a slight mustache or a few 
straggling dark hairs on other parts of the face often appear. 
These growths seldom annoy them much, as they are ac- 
cepted as evidences of advancing years. The case is very 
different when a young woman is afflicted with a beard, 
and most of the patients who apply for relief from their 
facial hair are between twenty and thirty-five years old. 
In them the hair generally begins to grow so as to be no- 
ticeable at about the eighteenth year of age. To get rid 
of the trouble the tweezers are first resorted to ; then 
depilatories are tried ; sometimes burning is attempted, 
and as a final refuge the razor is used. All the time the 
hair grows coarser and more abundant. Some of these 
women shun company, keep themselves shut up all day, 
their health deteriorates, and, constantly brooding over 
their misfortune, they are prone to become hypochondriacal 
and melancholic. The amount of hair present in these 

iYirchow's Archiv, 1868, xliv., 418. 

2 The Hair : its Diseases and Treatment. Detroit, 1881. 

3 Jackson : Diseases of the Hair and Scalp. New York, 1887. 



308 DISEASES OF THE SKIN. 

cases varies. Perhaps the commonest growth is the mus- 
tache alone. In most of my cases the hair has grown 
thickest and coarsest under the chin and upon the front of 
the throat. It is rare, even in the best-developed cases, 
to have much hair under the lower lip. Sometimes the 
growth is as complete, as heavy, and as coarse as is met 
with in men. The skin in many cases is coarse, muddy, 
greasy, and studded with acne. 

From time to time cases of transitory hypertrichosis 
have been reported. This has been noticed during the 
treatment of a fractured limb, the hair being much more 
prominent upon the part that has been kept quiet and 
warm. In some of these cases the increase is probably 
more apparent than real, the hair not having been rubbed 
off by friction. Likewise, after injury to nerves the hair 
sometimes becomes hypertrophied, only to fall out after 
recovery. Continued irritation of a part, as by blisters, 
may stimulate hair-growth which may or may not be 
transitory. The most interesting of this group of cases 
is that comprising those of hirsuties occurring during 
pregnancy, and disappearing again after some months. 
Wilson reported a case of delayed appearance of menstru- 
ation in which hair grew upon the face. After the men- 
strual function was established the hair ceased to grow 
and gradually disappeared. 

Etiology. The cause of hypertrichosis is very ob- 
scure in some of its forms, while in other varieties we can 
more readily discover it. In general congenital hirsuties 
heredity plays an important part. But hereditary tend- 
encies will not explain the first appearance of these con- 
genital cases. Virchow endeavored to account for them 
upon the theory of nervous influence, founded upon the 
fact that in the Kostroma people the lack of development 
of the teeth and jaws was in the same zone as the overde- 
velopment of the hair on the forehead, nose, cheek, and ears; 
these regions all being supplied by branches of the trigem- 
inus or fifth cranial nerve. Unna's theory of congenital 
hypertrichosis is that it is due to a persistence of the foetal 



HYPERTRICHOSIS. 309 

or primitive hair ; the change of type between the primi- 
tive and permanent hair not taking place. 

The cause of acquired hirsnties is, in some cases, not 
far to seek. Heat and moisture will apparently increase 
the growth of hair, just as they favor the growth of vege- 
table life. Thus the hair has grown luxuriantly under the 
stimulation of poultices, and on the limbs when confined 
in a fracture-box. To these factors must be added an in- 
crease of the flow of blood to the part. Increase of the 
flow of blood will stimulate hair-growth independently of 
heat and moisture. At least Prentiss's case of hair grow- 
ing more luxuriantly and coarser under the use of pilo- 
carpine, which causes hyperemia of the skin, would seem 
to indicate this. Hypertrichosis following injury to nerves 
is probably dependent upon vasomotor disturbances. The 
growth of hair upon exposed parts, as upon the arms and 
chest of laboring men, sailors, and the like, is due to the 
local irritation of the sun and wind. 

Kow we come to the more obscure cause of facial hirsu- 
ties in women. To account for this, numerous hypotheses 
have been formed. Probably the one most generally 
accepted is that it is in some way connected with derange- 
ment of the uterus and appendages. Because in some 
bearded women there has been some evident derangement 
of the sexual organs, it has been affirmed that some similar 
derangement is present in all. This is on a par with the too 
loosely accepted idea that the too free use of alcohol is the 
only cause of rosacea. In the cases I have met with, the 
majority were as free from uterine trouble as the rest of 
their sex. While it is true that some of these women are 
of masculine build, and have a masculine voice, most of 
them do not exhibit these characteristics. In some cases, 
however, there does seem to be some relation between 
the reproductive organs and the growth of the beard. 
Heredity is often well marked. It is improbable that 
attempts at destroying the fine hair causes the develop- 
ment of the coarse hair. It is more likely that it only 
strengthens its growth. Women are prone to trace the 



310 DISEASES OF THE SKIN. 

appearance of hair on the face to the use of vaseline, cold 
cream, and the like. There is no scientific foundation for 
this. 

An interesting study of the relation between hirsuties 
in women and insanity was made by Hamilton. 1 He re- 
gards hair-growth on the face in women as the inevitable 
result of the overactive and continuous exercise of the 
uterine and ovarian functions. He believes it to be of 
neuropathic origin, connected with disorders of the fifth 
cranial nerve ; and that when it occurs upon the face of 
an insane person it is indicative of an unfavorable form of 
insanity, especially if the subject has not reached middle 
life. 

We may sum up the evidence on the etiology of facial 
hirsuties in this way : While at times there appears to be 
a relation between the uterine, or, more properly, the 
menstrual function, and the growth of hair on the face, 
shown by a decrease or deficiency of the first, and an in- 
crease of the second, still in the majority of cases no such 
relation is discoverable, and it must be viewed as a de- 
formity, or a freak of Nature, or as a matter of inher- 
itance. 

Treatment. For general hypertrichosis we can prac- 
tically do nothing. This, not because we cannot destroy 
hair so that it will not grow again, but because of the 
great amount of time it would take to destroy it. 

The only form of hirsuties which urgently calls for re- 
lief is that occurring upon the face of women. In 1875 
Dr. Michel, of St. Louis, devised the method of removing 
the hairs in trichiasis by means of electrolysis, which was 
taken up by Dr. Hardaway, of the same city, for the re- 
moval of superfluous hair. The question is often asked : 
" Is the removal, by this method, permanent ?" This 
question may be answered, " It is, without a shadow of 
a doubt." The object being to destroy the papilla, and 
that being very small and often placed at an unexpected 
angle to the surface of the skin, it is not possible always 
!The Medical Record, 1881, xix., 281. 



HYPERTRICHOSIS. 311 

to accomplish this at the first attempt ; but with patience 
and the necessary skill, it will finally be permanently de- 
stroyed. At times, after the dark, coarse hairs haye been 
removed, there will be found a number of finer and lighter 
hairs. This appearance is due partly to the uncovering 
of these hairs, and partly it may be, to lanugo hairs be- 
coming stronger under the stimulation of the operation. 
In most cases, with proper care and the use of a fine 
needle, the amount of scarring will be very slight, amount- 
ing to nothing more than fine punctate cicatricial spots. 
In some peculiarly irritable skins it is very difficult to 
prevent the formation of plainly visible scars. The upper 
lip is also prone to scarring. If the proper conditions are 
not observed, the operator must expect to produce a good 
deal of disfigurement. 

The amount of pain experienced by the patient will 
vary greatly. Certain parts of the face are far more sen- 
sitive than others. On the whole, the pain does not 
amount to much. After a time the skin seems to become 
tolerant of the action of the current and the patient no 
longer complains. Hyper-pigmentation may be produced 
by the operation. This is a very rare complication, and 
is only mentioned by way of warning. 

The instruments needed for the operation are a good 
twenty-cell zinc-carbon (galvanic) battery, a sponge elec- 
trode, a proper needle-holder, a fine needle, a pair of epi- 
lating-forceps, and, if the operator's eyes are not good, a 
lens of low power. Any sponge electrode will answer. 
There are various patterns of needle-holders, any one of 
which may be used. It should be long enough to be held 
with ease, and not too long to be readily manipulated. 
The most essential instrument is the needle. Hardaway 
recommends a needle made of iridium and platinum. He 
claims that it will follow the direction of the hair follicle, 
and more surely hit the papilla than will a steel needle. 
I have had most satisfactory results with a jeweller's in- 
strument called a " steel broach." These come in many 
grades ; those known as Nos. 5 and 7 are serviceable 



312 DISEASES OF TEE SKIN. 

ones. A lens is generally not needed. Dr. Piffard has 
invented a needle-holder with lens-attachment, which he 
has found useful. A galvanometer is not essential, but 
very desirable. 

A good light is necessary for the operation, and a cloudy 
day is a bad one for working. An operating or reclining 
chair is a comfort, and the patient should be so placed that 
the part to be operated on is on a level with the operator's 
eye. The operation is done in the following manner : The 
patient, being in position, is to be given the sponge elec- 
trode attached to the positive pole of the battery, and told 
to hold it in one hand. The hair to be extracted is then 
seized with the forceps, and put slightly on the stretch in 
the direction in which it naturally grows. The needle, at- 
tached to the negative pole, is then inserted parallel with 
the hair and into the follicle. One soon learns to know 
whether the follicle is entered or not by the sense of touch. 
When the follicle is entered the needle glides along 
smoothly ; when it is not entered a sense of resistance is 
communicated to the fingers as the skin is punctured. 
The depth to which the needle is to be thrust will vary 
with the case. Roughly speaking, it is from -^ to T 3 g of 
an inch. The needle being inserted, the patient is told to 
place the palm of the disengaged hand over the sponge 
electrode. In a few moments there will be frothing about 
the needle, and in from half a minute to a minute or more 
the hair will come away upon the very slightest traction. 
The hand is to be removed from the sponge before the 
needle is withdrawn from the follicle. 

The hair must not be pulled on with any force, for the 
ease with which it leaves the follicle is a guarantee of the 
completeness of the operation. The hairs must not be 
extracted in close proximity, because the inflammatory ac- 
tion thus set up will lead to more or less deep ulceration 
and subsequent prominent scars. It is best to extract 
only the coarser hair and to leave the lanugo hairs alone. 
The strength of the current to be used will depend upon 
the quality of the patient's skin and the recentness of the 



ICHTHYOSIS. 313 

filling of the battery. Six cells are the fewest I have 
used, and fifteen the greatest number. More exactly, a 
current-strength of J- to 1 J milliamperes. 

The patient should be directed to bathe the face in hot 
water and to anoint it with cold cream several times dur- 
ing the day following the operation. 

T. Bloebaum l advocates the use of galvano-canstic 
needles as superior to electrolysis for the destruction of 
hair. A special needle is used by him, and he destroys 
one hundred hairs in fifteen minutes. He claims for his 
method not only greater celerity, but also less scaring and 
pain. The micro-brenner of Unna has its advocates. 

Hypohydrosis. See Anidrosis. 

Hystricismus. See Ichthyosis. 

Ichthyosis (Fk-thr-o'-srs). Synonyms : Xeroderma ; 
Xeroderma ichthyoides ; Icthyosis vera, seu congenita ; 
Sauriasis ; (Fr.) Ichthyose ; (Ger.) Fischschuppenaus- 
schlag ; Fish-skin disease. 

Ichthyosis is a congenital, general or partial, chronic 
disease of the skin, characterized by dryness, harshness, 
and scaling of the skin, and sometimes by the develop- 
ment of warty-looking growths. 

Symptoms. Though the disease is congenital it usually 
does not show itself until after the second month, and 
sometimes not until the second year. There are four 
varieties of the disease, namely, xeroderma, ichthyosis 
simplex, ichthyosis hystrix, and ichthyosis congenita. 

Xeroderma is the mildest grade of the disease. The 
skin is dry, harsh, slightly scaly, grayish or dirty-looking, 
and its natural lines are more pronounced than usual. 
Upon the extensor surfaces of the limbs it is particularly 
marked, and here too it is accompanied by keratosis pilaris. 
It is most annoying to young women who want to Avear 
short-sleeved dresses. It is doubtless far more common 
than statistics show, as it very often is very slight in 
amount. 

Deutsche Med. Zeit, 1897, xviii., 609. 



314 



DISEASES OF THE SKIN. 



Ichthyosis simplex. This is a more severe grade of the 
disease in which the skin is dry, harsh, and scaly, and also 
divided off into small diamond-shaped or polygonal figures 
(Fig. 36). While the whole cutaneous surface may be 
involved, the disease is usually most pronounced upon the 
extensor surfaces of the legs and arms. The face, scalp, 
palms, and soles are often spared. The skin about the 




Ichthyosis. 

extensor surfaces of the elbows and knees is generally 
thrown into well-marked folds, while the flexor surfaces of 
the same joints are unaffected, the skin in these situations 
being soft and natural. While upon the extremities the 
disease is well developed, upon the trunk it may assume 
more of the xerodermatous form. When the face and 



ICHTHYOSIS. 315 

scalp are affected they are simply very scaly, while on the 
palms and soles we have accentuation of the normal lines. 
In a typical case the skin, especially of the extremities, 
will be grayish, greenish, or blackish-green in color, dry, 
and the little polygonal plates will be attached in their 
centers and turned up slightly at their edges, so that they 
appear depressed in the centers. The amount of loose 
scaling is sometimes abundant, but usually moderate in 
amount. The hair, if the scalp is involved, is dry. The 
nails are often pitted. Ectropion may result in those rare 
cases in which the disease affects the face severely. Itch- 
ing is often complained of, and eczema may complicate 
matters. There is a marked absence of perspiration, and 
lessened sebaceous secretion ; and the patients are sensitive 
to cold. The disease is usually worse in cold weather. 

Ichthyosis hystrix is one of the rarest forms of the dis- 
ease. It is never general, but confined to a limited area, 
or to a number of areas. It is often unilateral, and at 
times seems to follow the course of a nerve in its distri- 
bution. It occurs in the form of horny papillary growths, 
that may be isolated and pin-point-sized ; or massed 
together into elevated, warty, dark -green plates, traversed 
by deep lines ; or arranged in long lines of parallel rows. 
When in the last form it has been called nerve naevus, 
nsevus verrucosus, neuropathic papilloma, papilloma neu- 
roticum, and the like. Ichthyosis hystrix may be present 
alone, the rest of the skin being normal, or it may occur 
as a part of ichthyosis simplex. 

Ichthyosis congenita is the most rare form of the disease. 
It is also called Keratoma follicularis, Keratosis diffusa, 
seu epidermica, seu intra-uterina, and the " Harlequin 
foetus. " It is considered by some to be a general sebor- 
rhea. It is present at birth, the skin being covered with 
fatty epidermic plates cracked in all directions and 
arranged transversely to the axis of the body. The fis- 
sures may extend into the corimn. The eyes are held 
partly open, or there may be ectropion ; the lips cannot 
be moved ; and the feet are contracted and deformed, 



316 DISEASES OF THE SKIN, 

The color is yellowish-white or grayish. The scrotum 
and penis may not be involved. These infants are either 
born dead or survive birth but a short time. 

There are also cases of ichthyosis intra-uterina in which, 
after the removal of the vernix caseosa, the skin looks 
red, glazed, and dry, and then soon assumes the character- 
istics of ichthyosis simplex. 

With the exception of ichthyosis congenita, the disease 
does not show itself until some months after birth, but by 
the second year it has made its appearance. As a rule, it 
increases in severity as the patient grows older, until adult 
age, when it usually remains stationary, or perhaps im- 
proves a little. It is a chronic disease and shows no 
tendency to get well. It does not seem to affect the 
patient's health, and it should be regarded rather as a 
deformity than a disease. Occasionally mental weakness 
and other congenital defects have been noticed. 

Etiology. We know of no cause for the disease be- 
yond heredity, which may be direct, skip a generation, or 
be through a lateral branch. Many cases occur without 
manifest heredity. It attacks both sexes about equally. 
It shows a tendency to occur only in one sex in certain 
families, while in other families both sexes are equally af- 
fected. It is a congenital defect in the development of 
the skin with a disturbance of the functions of perspira- 
tory and sebaceous glands. 

Diagnosis. The disease is so unique that if its char- 
acteristics are remembered there can be no difficulty in di- 
agnosis. There is no other disease commencing in infancy 
that at all corresponds to ichthyosis simplex. Xeroderma 
may resemble a mild grade of squamous eczema, but has 
not its history. Sometimes we meet with a dry skin that 
is not ichthyosis, but is only a passing state and has not 
existed from infancy. Ichthyosis hystrix may resemble 
common warts, and sometimes the latter may be present, 
but differs from them in its color and distribution. Ich- 
thyosis congenita differs from seborrhoea in not being 
removable by soaking in oil ; and by proving fatal. 



IMPETIGO. 

Treatment. The treatment is largely pa 
The free use of Russian baths or of prolonged 
baths, simple or with soda, and washing with soap, fol- 
lowed by inunctions of vaseline, glycerin, lanolin, or oil, 
such as cocoa-butter, will keep the skin supple. Kaposi 
recommends a 5 per cent, naphthol ointment, or a 2 per 
cent, solution in spiritus sapo. viridis, or cod-liver oil, in 
conjunction with naphthol soap. Andeer l recommends a 
3 to 20 per cent, ointment of resorcin well rubbed in, and 
covered with a bandage, and claims a cure in eight days. 
Sulphur ointment has also been recommended. The daily 
application of half an ounce to an ounce of glycerin in a 
pint of water sometimes proves helpful. Whatever is 
used must be persisted in. Ichthyosis hystrix may be re- 
moved by curetting, or by salicylic acid plaster, 20 per 
cent, strength ; or by the same drug in alcohol or collodion, 
a drachm to the ounce. 

Besnier recommends, as adjuvants to the local treat- 
ment, regular gymnastic exercise and the internal admin- 
istration of cod-liver oil. Thyroid extract has been used 
with benefit in some cases. It should never be used un- (J 
less the patient can be watched by the physician, as it is a 
dangerous remedy. 

Prognosis. The prognosis is good as to life, bad as to 
cure. Thus far it has proved incurable in the hands of 
most physicians. All one can hope to accomplish is to 
render the patient comfortable and fit to mingle with his 
kind by repeated courses of treatment. Ichthyosis con- 
genita is fatal in a few days, if the child is not born dead, 
as is usually the case. 

Ichthyosis Follicularis. See Keratosis follicularis. 

Ichthyosis Sebacea. See Seborrhoea sicca. 

Idrosis. See Hyperidrosis. 

Ignis Sacer. See Zoster. 

Impetigo (Fm-pe^-i'-go) is a name that was applied at 
one time to all pustular eruptions. At the present time 



318 DISEASES OF THE SKIN. 

there are but three varieties described, namely : Impetigo 
or impetigo simplex ; impetigo contagiosa ; and impetigo 
herpetiformis. The right of the first-named variety to be 
recognized as a distinct affection is denied by systematic 
writers of all nations but our own. Our own writers 
largely follow Duhring in their description of the disease, 
and as soon as they vary from his description, it seems to 
me that, instead of simple impetigo, they describe the con- 
tagious form. I have never recognized a case, and shall 
here follow Duhring. 

Impetigo simplex. Symptoms. The appearance of the 
disease may or may not be preceded by loss of appetite, con- 
stipation or malaise. The eruption consists of one to a 
dozen or more pustules that are pustules from the begin- 
ning. They are split-pea to finger-nail in size ; rounded ; 
and raised above the surface of the skin. They have thick 
walls, a more or less marked areola, little surrounding in- 
filtration, and no central depression. Their color is yel- 
lowish or whitish. They manifest no disposition to rup- 
ture, are discrete and disseminated, and do not incline to 
coalesce. While they may occur anywhere they are seated 
by preference on the face, hands, feet, and lower extremi- 
ties. Itching and burning are absent, as a rule. The 
course of the disease is acute, its duration being several 
weeks. The pustules gradually undergo absorption and 
dry into a crust, or they may be ruptured by external in- 
jury. The crust when it falls leaves a reddish base with- 
out pigmentation or scar. It is not contagious, and occurs 
mostly in children. 

Such is the disease as described by Duhring. It will 
be seen by reading the next section that it bears a strong 
resemblance to impetigo contagiosa. He differentiates it 
from impetigo contagiosa on account of its being pustular 
and not vesico-pustular from the start, its deeper seat, and 
its being more raised and not umbilicated. 

Impetigo Contagiosa. Synonyms : Porrigo contagiosa ; 
Impetigo parasitica. 



IMPETIGO CONTAGIOSA. 319 

An acute, inflammatory, contagious disease, occurring 
especially on the face, hands, and exposed parts, and char- 
acterized by the appearance of vesico-pustules and bullaa. 

Symptoms. By Tilbury Fox, who first described the 
disease, and others who followed him, its onset is said to 
be marked by slight febrile disturbances. These are very 
slight, and I have not satisfied myself as to their occur- 
rence in the many cases that I have seen, except inciden- 
tally as part of some digestive disorder that may be present. 
The eruption consists of vesico-pustules that come out in 
crops. They are of various sizes, but average that of a 
split pea. They are at first surrounded in well-marked 
cases, with a red halo, which soon fades. They tend to 
increase slowly in size, and sometimes assume an annular 
shape. They are not fully distended, but flaccid, and 
not infrequently upon the hands will bear a strong re- 
semblance to a burn of the second degree. If the covers 
of the vesicles or small bulke are not disturbed, their con- 
tents in a few days will dry up, and the vesico-pustule 
will change into a straw-yellow granular crust, which is 
placed superficially upon the skin with its edge somewhat 
detached, and, it may be, turned up. In fact, it looks 
" stuck on." When the crust is removed or falls of itself, 
there is exposed an erythematous spot, which in a short 
time will disappear and leave no trace of its existence. If 
the vesicles are torn by scratching, or if by any other 
means their covers are removed, we shall find very super- 
ficial losses of substance — a moist surface covered with a 
slight purulent secretion or crusted lesions. Even this 
disappears and leaves no trace, passing through the ery- 
thematous stage in its course to recovery. Such are the 
appearances presented in the majority of cases. 

Besides this usual and typical form we meet with an- 
other and rarer variety, in which, instead of vesico-pus- 
tules, there are larger bullae. These may be several inches 
in their long diameter, are of irregular oval shape, not 
fully distended with fluid, and sometimes show a slight 
depression in their centers. Their, contents are at first 



320 DISEASES OF THE SKIN. 

serous, but soon become sero-purulent. They seem to be 
longer preserved than the vesicles, but otherwise run the 
same course. At first they have a slight zone of redness 
about them, but this soon disappears. They either are 
formed by two or more vesico-pustules running together, 
or spring up of themselves. They may attain their full 
size at once, or increase slowly. Rarely do they exist 
alone ; generally the typical vesico-pustules w T ill be found 
in their neighborhood or elsewhere on the body. It is the 
bullous form that is liable to be mistaken for pemphigus. 

Impetigo contagiosa is located principally upon the 
face, most often on the chin, and on the hands ; it may 
also occur upon the scalp, legs, and trunk, especially in 
infants. According to my experience, the bullous form 
is most often seen upon the trunk. The lesions of both 
varieties are discrete ; exceptionally two or more may run 
together. They are superficial, and rarely very numerous. 
The bullous lesions are generally widely separated from 
one another. The disease does not run any definite course, 
and may last weeks or months ; a slight amount of itch- 
ing is sometimes present. 

Etiology. It is, as its name indicates, very conta- 
gious, and often occurs in epidemics. When one case is 
met with in dispensary service, several more may be ex- 
pected in children of the same family or neighborhood. 
It is readily inoculable both on the subject of the disease 
and on others. Not infrequently we see a mother or 
other attendent of a child with the characteristic lesions 
of impetigo contagiosa upon the arms, derived from carry- 
ing the child suffering with the same disorder. What the 
contagious element may be is not yet determined with 
certainty, though various investigators have described 
several parasites as the cause of the disease. We know 
that all pus is under certain circumstances inoculable, and 
hence it has been maintained that there is no such dis- 
ease, properly speaking, as contagious impetigo. But 
when we succeed in inoculating from an ordinary impetigo 
pustule, we produce an ordinary impetigo pustule, not 



IMPETIGO CONTAGIOSA. 321 

the characteristic vesico-pustule of impetigo contagiosa. 
It has been stated by some authorities that the disease 
is due to an inflammation set up by lice on the head 
of the particular case or can be traced back to some other 
case of pediculosis. In some cases phtheiriasis capitis 
may be present, because both diseases occur with special 
frequence in children of the poor. In my own experi- 
ence, in most cases no such relationship can be traced. 
A number of cases have been reported of the occurrence 
of contagious impetigo shortly after the fall of vaccine 
crusts, and thus has been suggested the possible connec- 
tion between impetigo and vaccinia. It is more frequent 
in the warm months than in the cold. Children furnish 
the vast majority of the cases. 

Diagnosis. Impetigo contagiosa is diagnosticated by 
the presence of discrete, partially distended vesico-pus- 
tules, which are located upon the exposed parts — head, 
face, and hands — in most cases ; these are sometimes 
grouped, run an acute course, and dry up into straw- 
yellow " stuck-on " crusts. It is sometimes preceded by 
slight constitutional disturbances, and accompanied by a 
slight amount of itching. It must be differentiated from 
simple impetigo, pustular eczema, varicella, scabies, pem- 
phigus and possibly ecthyma. 

The lesions of simple impetigo are pustules from the 
start, while those of impetigo contagiosa are first vesi- 
cles and then vesico-pustules. The pustules of impe- 
tigo are prominently raised, and run no definite course. 
The vesico-pustules of impetigo contagiosa are flattened, 
and run a rather definite course. The crusts of impetigo 
are generally greenish, while those of the contagious form 
are yellowish. Impetigo is not so readily inoculable as is 
impetigo contagiosa, and is much more widely dissemi- 
nated, as a rule. Simple impetigo is a deeper process 
than the contagious form. 

Pustular eczema is itchy ; its pustules tend to break down 
quickly, run together, and form large patches, which soon 
become covered with a greenish or blackish crust. These 
21 



322 DISEASES OF THE SKIN. 

phenomena are entirely foreign to impetigo contagiosa. 
Eczema does not present vesico-pustnles nor bullae, as a 
rule, and shows slight tendency to spontaneous recovery. 
Varicella is an acute contagious disease, with constitutional 
symptoms in most cases. Its vesicles are smaller than 
those of impetigo contagiosa, and they run a definite 
course peculiar to themselves. They are widely distrib- 
uted over the whole surface, usually appear first on the 
trunk, sometimes occur on the fauces, and not infrequently 
leave pitted scars. Contagious impetigo is in most cases 
limited to the exposed parts, it never occurs upon the 
fauces, and its lesions leave no trace. The crusts of vari- 
cella are small, while those of contagious impetigo are 
large. 

The diagnosis from scabies offers little difficulty. In 
fact, the location of both diseases upon the back of the 
hands is their strongest point of resemblance. When we 
bear in mind that scabies is very itchy, that it occurs 
usually as a copious eruption upon the hands, wrists, and 
forearms, about the umbilicus, or the nipples of females 
and the genitals of males ; that scratched papules and 
pustular lesions are more characteristic of it than vesicles, 
and that it presents the pathognomonic furrows, we should 
not confound it with impetigo contagiosa, which has none 
of these symptoms. Further, impetigo will, in almost all 
cases, occur upon the face at the same time with the hands, 
and that location is very rarely attacked by the itch mite. 

The diagnosis from pemphigus is by no means always 
easy. The occurrence of the bullous form of contagious 
impetigo is so rare that it is no wonder it is mistaken for 
pemphigus. Indeed, it is probable that not a few of the 
cases reported as acute pemphigus in children, which pos- 
sessed apparent contagious qualities, were instances of this 
bullous form of impetigo. The diagnosis between the two 
diseases can scarcely be made with certainty by the appear- 
ances of the bulla? alone ; we must also take into consider- 
ation the general course of the disease. The differential 
diagnosis may be given as follows : 



IMPETIGO HERPETIFORMIS. 323 

Pemphigus. Impetigo Contagiosa 

(Bullous form). 

1. Occurs chiefly in adults. 1. Occurs chiefly in children. 

2. No source of contagion can be found. 2. A source of contagion can usually he 

found. 

3. No particular sites of preference ; if 3. Met with most often upon the trunk, 

anything, it is most frequent on the sometimes it may occur on the face, 

extremities. hands, or extremities. 

4. Chronic in its course ; marked by fre- 4. Acute iu its course, rarely lasting 

quent relapses ; may return from more than a few weeks, 

year to year. 

5. Bulla? are fully distended with a 5. Bullae not fully distended, but flac- 

clear fluid, so that their covers ap- cid, and contain serorpurulent fluid, 

pear tense. They often spring up They may have a welt-marked red 

out of the sound skin without halo while slowly attaining their 

areola. full size. Characteristic vesico-pus- 

tules are generally present else- 
where at the same time. 

6. Lesiorjs often occur in great numbers, 6. Lesions, few in number, do not in- 

so as to cover the whole body, and volve the whole body, and itch but 

at times are pruriginous. little, if at all. 

7. Disease obstinate to treatment, and 7. Disease yields readily to treatment ; 

prognosis usually grave. prognosis uniformly good. 

Ecthyma is probably only a form of impetigo contagiosa 
that occurs in broken-down subjects. It affects by prefer- 
ence the lower extremities, is seen most often in adults, 
and its lesions are deep pustules, which are highly inflam- 
matory and painful. 

Treatment. The treatment of the usual form is to 
direct the affected parts to be scrubbed with warm water 
and soap, and covered with a 5 per cent, carbolized vase- 
line, or with oxide of zinc ointment with carbolic acid in 
the same strength, or with the ointment of the ammoniate 
of mercury diluted to half its strength. If there is a good 
deal of crusting, the crusts may readily be removed by 
soaking them with oil or warm water, after which the appli- 
cations mentioned may be made. In the bullous form it 
is well to prick the bullae at their most dependent part, 
and let the fluid escape, after which the lesions may be 
treated as just indicated. 

Prognosis. The prognosis of impetigo contagiosa is 
always good • so readily is it cured that the patients sel- 
dom present themselves a third time at the dispensary. 

Impetigo granulata. See Pediculosis. 

Impetigo Herpetiformis. This disease was first de- 
scribed by Ilebra 1 in 1872. 

1 Wiener med. Wochenschrift, 1872, No. 48. 



324 DISEASES OF THE SKIN. 

In this country it is exceedingly rare, only a few cases 
having been reported. We owe to Hebra and Kaposi 
nearly all we know about the disease, and it is from Ka- 
posi 1 that the account here given is taken. 

The disease begins with an eruption of pustules in the 
genito-crural region, about the umbilicus, on the breasts, 
and in the axillae ; later upon various other locations. 
The pustules are crowded together, grouped, pinhead size, 
with at first opaque, and later greenish-yellow contents. 
They dry into a dirty-brown crust, while immediately 
around them new pustules appear in double or threefold 
circles, by the drying of which the crust is enlarged. The 
disease spreads by the growth of the individual groups and 
by the coalescence of neighboring ones. Underneath the 
crusts the skin appears red and covered with new epi- 
dermis ; or deprived of epidermis, moist, infiltrated, and 
smooth ; or papillary, but never ulcerated. Within three 
or four months nearly the whole skin is involved, swollen, 
hot, covered with crusts, showing torn and excoriated 
places, with here and there circles of pustules. The 
mucous membrane of the tongue may show circumscribed, 
gray patches. There is a continuous remittent fever, and 
each outbreak of pustules is marked by chills, high fever, 
and dry tongue. Nearly all cases prove fatal. The dis- 
ease has affected almost exclusively pregnant women, only 
one man having been reported with the malady. Delivery 
has not stopped the course of the disease. It is probably 
of septic origin. 

Diagnosis. The disease is stated by Kaposi to differ 
from dermatitis herpetiformis in being only pustular ; in its 
peculiar location and manner of spreading ; in the absence 
of itching ; in the severe constitutional symptoms ; and in 
its lethal ending. 

Treatment. No treatment has proved successful. 
We can only do our best to nourish the patient ; and by 
means of baths, dusting powders, or alkaline lotions render 
her as comfortable as possible. 

1 Pathologie und Therapie der Hautkrankheiten, 



KELOID. 325 

Induratio Telae Cellulosae Neonatorum. See Sclerema 
neonatorum. 

Inflammatory Fungoid Neoplasm. See Mycosis fun- 
goides. 

Intertrigo. See Erythema intertrigo. 

Iodic Acne. See Dermatitis medicamentosa. 

Itch. See Scabies. 

Juckblattern. See Prurigo. 

Kahlheit. See Alopecia. 

Kelis. See Keloid. 

Keloid (KeF-oid). Synonyms : Kelis ; (Fr.) Cancer 
tubereux, Cheloide ; (Ger.) Knollenkrebs. 

A connective-tissue new growth in the skin, occurring 
most commonly upon the chest ; characterized by hard- 
ness, by a pinkish color, and by sending off prolongations 
in all directions. (Fig. 37.) 

Symptoms. It is usual to divide keloids into two va- 
rieties, one of which is called the true or spontaneous 
keloid, and the other the false or secondary keloid the re- 
sult of injuries. Of late the opinion is gaining ground 
that no such distinction can be made and that even the 
true keloid results from some slight injury. As most 
commonly met with it consists in a single, firm, hard, 
pinkish, freely movable, oval or elongated, elevated tumor 
upon the upper half of the sternum, from which claw-like 
processes are given off in all directions. While there may 
be but one tumor, the lesions may be multiple, there being 
either one large and several small ones upon the chest, or 
many scattered over the body. They begin as small, 
pinkish elevations and gradually enlarge until they attain 
a certain size, when they may remain stationary, or else 
slowly grow. They assume all sorts of shapes and sizes. 
Sometimes they have an even surface, sometimes they are 
nodular. They may be quite small, or they may be so 
large as to run nearly half-way across the chest. Then 



326 



DISEASES OF THE SKIN. 



the appearance is as if the skin were drawn up into the 
tumor. The epidermis is smooth over them, and the pink 
color is due to the dilated blood vessels. Sometimes the 
color is white. Though they are rarely met with on the 

Fig. 37. 




Keloid. 



face in the white races, they are very common upon the 
face of the negro. They are often attended by a good 
deal of pain, or pruritus, or pricking sensations. 

Beside this form of keloid, that may or may not be 
spontaneous, we have the evident scar keloid that occurs 
over the site of an injury to the skin. These have fol- 
lowed syphilides that have destroyed the skin, variola 

a From G. H. Fox's Photographs of Skin Diseases. 



KELOID. 327 

pustules, psoriasis, a blister, or acne. 1 They may be lim- 
ited to the side of the previous lesion, or spread beyond 
it. This form of keloid is very often seen on the face of 
the male negro who shaves, the checks and chin being 
studded over with small, hard, white elevations. The 
hypcrtrophkd scar resembles keloid, but never spreads be- 
yond the limits of the injury, has no claw-like processes, 
is not so pinkish, nor so permanent. 

Etiology. We know scarcely anything as to the 
cause of keloid, and can only beg the question by saying 
that it is a predisposition on the part of the skin. It is 
probable that some minute injury precedes the tumor. 
The negro race is peculiarly prone to the disease. Sex is 
without influence, and it may occur at any age, though 
rare before puberty and in old age. Histologically the 
structure of the keloid is similar to that of the cicatrix — 
that is, it is a dense fibrous connective-tissue growth which 
has its seat in the true skin. 

Treatment. As a rule, it is safest to leave the 
growths alone. Cutting them out is often disappointing 
in its results, as the growth is apt to return. Multiple 
scarifications followed by the application of acetic acid 
have been successful. Leloir and Vidal 2 recommend fol- 
lowing multiple scarifications with a boric-acid dressing. 
The next day mercurial plaster is to be applied, and 
changed every morning and evening. Perseverance in 
this method, they say, may result in a cure. Compression 
by means of an elastic bandage or by mercurial plaster 
sometimes reduces the prominence of the tumors. Harda- 
way has succeeded in removing one keloid and two hyper- 
trophied scars by means of electrolysis, and Brocq has 
commended the method. A stout needle must be used 
and multiple punctures made in all directions, and in the 
tissues for a space beyond the tumor. Galvanism is said 
to reduce hypertrophied scars. Andeer 3 recommends re- 

^urdon: Journ. Cutan. and Ven. Dis., 1882-3, L, 203. 
2 Ann. de derm. et. syph., 1890, No. 3. 
3 Centralbl. f. med. Wissenschaft, 1883, xxvi., 785. 



328 DISEASES OF THE SKIN. 

sorcin and a bandage. S. Tonsey * advocates the use of 
thiosinamin and reports some favorable cases. It may be 
used either hypodermically once a day or every other day, 
12 to 15 mimins of a 10 per cent, solution in equal parts 
of pure glycerin and sterilized water ; or by the mouth, 
3 grains being given during the day. Hypodermatic in- 
jections of morphine, or the application of belladonna 
ointment, may be necessary to relieve pain. 

Prognosis. It is possible for keloids to undergo 
spontaneous involution. This is especially the case in 
the scar keloid following syphilis. Usually this cannot 
be expected. 

Keloid of Addison. See Morphoea. 

Keloid of Alibert. See Keloid. 

Keratodermia excentrica. See Porokeratosis. 

Keratolysis exfoliativa is the name applied by A. Sang- 
ster 2 to a case of congenital exfoliation of the skin which 
resembled ichthyosis, excepting that its scaling was more 
papery, like that seen in dermatitis exfoliativa. 

Keratosis Circumscripta. See Ichthyosis. 

Keratosis Diffusa seu Epidermica. See Ichthyosis con- 
genita. 

Keratosis Follicularis (Ke 2 r-aVos^ 2 sfo 2 l-i-k / u 2 -lar 3 -is). 
This is a rare affection of the skin to which especial at- 
tention has of late been given. It is probably the same 
as was described by Guibout by the name of acne sebacee 
cornee, and by Lesser as ichthyosis follicularis. The 
French have named it psorospermose folliculaire vegetante, 
but as this title was given it by Darier and Thibault in 
1889, under the idea that it was due to psorosperms, a 
pathological basis that is not yet proven, and as Morrow 3 
had already reported a case in 1886, with the title of ker- 

*N. Y. Med. Journ., 1897, lxvi., 624. 

2 Brit. Journ. Dermat, 1895, vii., 37. 

3 Journ. Cutan. and V en. Dis., 1886, iv., 257. 



KERATOSIS FOLLICULABIS. 329 

atosis follicularis, and White 1 another in 1889, under the 
same title, it seems to me best to retain their title. 

Symptoms. The disease affects nearly the whole cuta- 
neous surface, though both in Morrow's and White's cases 
the palms and soles were free. The eruption begins as 
pinhead-sized papules, which are firm and of the color of 
the skin. As they increase in size they become hyperse- 
mic ; still growing, they become hemispherical or flattened, 
with smooth or polished, dense adherent coverings of nail- 
like consistence, and varying in color from dull red to pur- 
plish, dusky red, brown, and brownish black. Some of 
them are excoriated by scratching and bear hemorrhagic 
crusts. These lesions are discrete, and the skin about 
them normal. They are located in the hair follicles. In 
places the lesions run together and form elevated areas 
with uneven surfaces and covered by thick yellowish or 
brownish, flattened horny concretions ; or there may be 
brownish or blackish plates. The patches feel rough and 
somewhat greasy. Here and there will be found papil- 
lomatous excrescences ; or enormously dilated follicular 
openings filled by comedo-like, firm, slightly projecting 
concretions forming hemispherical elevations, which when 
expressed are found to be hard and perfectly dry, leaving 
the follicle mouth patulous. The nails are coarse, slightly 
thickened, and ragged at their free edges. Boeck 2 says 
that they are often the seat of a marked hyperkeratosis 
without a trace of the disease itself anywhere in their 
neighborhood. The hard palate in White's case showed 
some follicular elevations. Pruritus is marked in some 
cases. A fetid odor is given off from the patient. 

Upon the scalp the disease appears for a long time as a 
seborrhoea sicca, but later the same elevations about the 
hairs can be made out as are seen upon the general integu- 
ment. Upon the backs of the hands and fingers the erup- 
tion presents the appearance of simple papillary growths, 
little pale-white, slightly raised, confluent and adherent 

^ourn. Cutan. and Gen.-Urin. Dis., 1889, vii., 201. 
2 Archivf. Derm, und Syph., 1891$ xxiii., 857. 



330 DISEASES OF THE SKIN. 

masses. Upon the palms and soles, instead of elevations, 
we find punctate depressions, and perhaps a hyperkera- 
tosis. In the axillse on account of maceration by sweat 
the masses are not so hard and horny, and the scales can 
be rubbed off, when a moist, red, warty surface is exposed. 

The course of the disease is a progressive one by the 
springing up of new lesions. It develops symmetrically. 
It seems to have no damaging effect on the health. It 
affects specially the scalp, axillse, inguinal region, abdomen 
below the umbilicus, backs of the hands and feet, and the 
wrists. 

Etiology. We know nothing positive about the etiol- 
ogy of this rare affection. White met with it in a father 
and daughter, and that would suggest the idea of heredity. 
The majority of the cases have been in males, and have 
begun before the sixteenth year. 

The psorosperm of Darier is regarded as simply a 
changed epithelial cell, and of no importance as an etio- 
logical factor. Darier and many other competent ob- 
servers hold that it is a true parasite, and the cause of the 
disease. The disease may begin at any age, cases having 
been reported as commencing in the first weeks of life, in 
the sixth, sixteenth, twenty-second, twenty-seventh, and 
thirty-sixth year, though most cases occur before the 
twenty-fifth year. 

Pathology. J. T. Bowen, who made a careful ex- 
amination of White's first case, says that " the disease is 
a keratosis of the epithelial lining of the mouths of the 
follicles, which, by extension downward, gradually pro- 
duces pouch-like depressions in the corium. The capacity 
for corneous metamorphosis is so great that the central 
portion becomes a firm horn, which by production of 
horny matter from below is gradually pushed out above 
the surface of the skin. There was no proof that the 
sebaceous glands were affected by the horny change." 
The keratosis may occur outside of the mouths of the 
follicles. Robinson found in Morrow's case that the 
changes occurred principally in the sebaceous glands. 



KERATOSIS PALMAEIS. 331 

Diagnosis. The disease differs from pityriasis rubra 
pilaris in lacking the constant and early involvement of 
the palms and soles, and the extensive, diffused, scaly 
dermatitis of the face, neck, and other parts, and in hav- 
ing horny plugs. 

Treatment. The proper treatment is yet undeter- 
mined. It might be well to try the methods found useful 
in ichthyosis. It is always a very obstinate disease, re- 
lapsing after the skin manifestations have been removed. 

Keratosis Palmaris et Plantaris. This is a form of 
congenital callositas. It has also been called Keratoma 
palmare et plantare hereditarium, ichthyosis palmaris et 
plantaris, tylosis palmse et plants. It is characterized by 
the appearance upon the palms and soles of masses of 
thickened skin of leathery consistence and yellow or 
brown color. They come without apparent cause and 
usually show a symmetrical arrangement. The palms or 
the soles alone may be affected, but it is always both 
palms or both soles that are affected. There is sometimes 
a zone of redness about the thickened plates. Sometimes 
the whole palm or sole is covered, sometimes the horny 
masses occur in islands. The plates may be shed period- 
ically only to re-form. The surface of the plates may be 
smooth or uneven. Hyperidrosis is frequently marked. 
The nails at times show hypertrophic changes. Pain may 
be complained of when the hands or feet are used. If the 
feet are affected, the pain may be so great as to prevent 
walking. 

Etiology. The disease is hereditary in many instances, 
and like ichthyosis tends to affect only one sex in a family. 
We do not know its cause, and we class it as a tropho- 
neurosis. It sometimes has been noted to follow the pro- 
longed ingestion of arsenic. 

Treatment. The plates may be removed by salicylic 
acid plaster ten to twenty per cent, strength. The same 
end is reached by poultices, the wearing of rubber sheet- 
ing, and the application of various plasters. A permanent 
cure can hardly be expected. 



332 DISEASES OF THE SKIN. 

Keratosis Pigmentosa. See Verruca senilis. 

Keratosis Pilaris (K. Pil-a'-ri 2 s). Synonyms : Lichen 
pilaris ; Pityriasis pilaris ; Ichthyosis seu hyperkeratosis 
follicularis ; Cacotrophia folliculorum ; (Fr.) Xerodermic 
pilaire, Ichthyose anserine des scrofuleux. 

Symptoms. As its name indicates, this is a disorder 
of cornification. It is characterized by a heaping up of 
the corneous cells about the mouths of the hair follicles in 
the form of small conical ; whitish, or grayish elevations. 
Between them the texture of the skin is normal ; its color 
may be unchanged or rosy, or of a grayish or brownish 
shade. It occurs chiefly upon the extensor surfaces of the 
limbs, especially upon the upper arm and thigh, but may 
occur anywhere. The appearance of the affected part re- 
sembles cutis anserina, being dotted over with little pin- 
head- to small-pea-sized papules, each one of which is 
either pierced by a hair or has a black dot at its summit 
indicating the mouth of the hair follicle. The papules are 
often scaly. The hair is either normal, broken off, or 
only to be found by opening the papule, when it will 
be seen curled up inside of it. The skin feels dry and 
harsh. There may be slight pruritus. Pityriasis capitis 
may be present at the same time. As the disease is 
attended by but slight, if any, subjective symptoms it 
is often over-looked. It is a chronic affection in most 
cases. 

Brocq describes a Keratosis pilaris of the face beginning 
as minute scaly papules about the hairs, which crowd to- 
gether to form patches and give a rosy or red tint to the 
skin. After a time the disease seems to destroy the fol- 
licle, and we find depressed scars arranged in rows or 
scattered about on the red patch. This bears some re- 
semblance to lupus erythematosus, and is the ulerythema 
ophryogenes of Taenzer. Besnier describes a somewhat 
similar condition as occurring upon the extremities. 

Etiology. The disease is sometimes congenital and 
often forms a part of ichthyosis. It is most common in 



KERION. 333 

women, and those who do not bathe frequently, or in 
whom there is cutaneous inactivity. 

Diagnosis. It differs from cutis anserina in being a 
permanent condition ; from the miliary papular syphilide 
in being whitish, grayish, or blackish, and not dark-red or 
raw-ham color, and in being removable by soap and water. 
Lichen scrofulosorum, occurs in strumous subjects and in 
well-marked circular or crescentic patches, which is for- 
eign to keratosis. Papular eczema differs in being very 
itchy, and in having red inflammatory lesions. Ichthyosis 
is a general affection of congenital origin, has peculiar 
markings of the skin, and is not limited to the hair 
follicles. 

Treatment. The vigorous use of green soap and water 
in an alkaline bath, followed by oil or vaseline, will re- 
move the evidences of the disease. Vapor or Russian 
baths may be used for the same purpose. Hyde prefers 
general cool baths containing one-quarter of a pound of 
common salt to each gallon of water, after taking which 
the skin is to be rubbed with a coarse towel or flesh-brush. 
As the affection is allied to ichthyosis it may be treated 
on the same plan, a new course of bathing being taken 
with each relapse. 

Keratosis Senilis. See Verruca senilis. 

Kerion (Ke'-ri 2 -o 2 n). Synonyms : Trichomykosis capil- 
litii ; Tinea kerion ; Kerion Celsi. 

Symptoms. This is a more or less chronic inflam- 
mation of the scalp or beard that most often is a form of 
ringworm, but may be produced quite independently of 
that disease. It is most commonly seen on the scalp. 
The affected part becomes red, oedematous, swollen, and 
boggy, and may assume a purplish color. Its surface is 
glazed, uneven, and studded with a number of yellowish 
suppurating points, or with foramina out of which oozes 
a sticky, viscid, gelatinous, transparent fluid. Sometimes 
suppuration may occur attended with a sero-purulent dis- 
charge. The swelling is round or oval in shape, and 



334 DISEASES OF THE SKIN. 

varies in size ; it may be but one or two inches in diam- 
eter, or as large as a turkey's egg. The pustules form 
about the hair in the early stage ; later the hairs fall and 
the discharge takes place from the openings of the hair 
follicles. If the tumor is opened, a thick, viscid material 
escapes. If the disease occurs with ringworm, the hair 
will be broken off. Permanent baldness may result if the 
inflammation is intense. There are more or less pain and 
tenderness, and at times itching and burning. The pos- 
terior cervical glands may be enlarged. 

Etiology. The disease is comparatively rare. It oc- 
curs chiefly in children of poor constitution. It is most 
commonly due to the trichophyton fungus passing deep 
down into the hair follicles, but may be caused by the ap- 
plication of irritants to the scalp, or follow eczema, favus, 
or sycosis of that part. 

Diagnosis. Kerion must be diagnosticated from abscess, 
a papilloma, a gumma, and a sebaceous cyst. An abscess 
is not preceded by ringworm, has no history of an irritant 
applied to the scalp, and may arise without any antece- 
dent disease of the scalp ; it is more painful ; it is often 
accompanied by a sensation of throbbing, by chilliness, 
fever, and general malaise ; when fully formed there is 
fluctuation, and w T hen opened it gives exit to pus. These 
symptoms are not met with in kerion. A papilloma is 
non-inflammatory, firm to the touch, and is unaccom- 
panied by a discharge. A gumma is usually accompanied 
by other signs of syphilis, and tends to break down 
and ulcerate. A sebaceous cyst is slow in its growth, the 
skin over it is normal, there is no discharge, and when 
opened it gives vent to a cheesy mass. A fatty tumor is 
a chronic, elastic, freely movable swelling, with normal 
skin over it. 

Treatment. In treating a case epilation should be 
performed in order to save the hair and give exit to the 
discharge. If some irritant application is the cause, that 
should be discontinued, and hot- water dressings, antiseptic 
solutions, or mild emollient applications employed. If 



KRAUROSIS VULVM 335 

the cause is ringworm, the remedies proper for that dis- 
ease should at once be used. What they are will be found 
under Trichophytosis capitis. 

Kleienflechte. See Chromophytosis. 

Kohlenbeule. See Carbuncle. 

Kopskurv. See Favus. 

Knollenkrebs. See Keloid. 

Kratze. See Scabies. 

Kraurosis (Kra 4 -ro'-si 2 s) Vulvae is a name proposed by 
Breisky 1 for a form of atrophy of the skin of the external 
genitals of women. The disease has its seat in the vesti- 
bule, the labia minora with the frenulum and prseputium 
clitoridis, the inner surfaces of the labia majora up to the 
posterior commissure, and the contiguous skin of the 
perineum. It gives rise to the appearance of a defect in 
the development of the normal folds of the vulva. At 
times the labia minora and the prseputium clitoridis are 
apparently wanting. The affected skin is white and dry, 
the epidermis is often thickened, and telangiectasic vessels 
are visible. Stenosis of the vulvar entrance may result 
and thus obstruction be offered both to coitus and parturi- 
tion. The cause is obscure ; possibly a long-continued 
blennorrhea, or a congenital defect, or a process analogous 
to leucoplakia buccalis. Treatment is of no effect. 2 

Krebs is the German for cancer. 

Kupferfinne. See Kosacea. 

Kupferrose. See Eosacea. 

Kupfriges Gesicht. See Rosacea. 

Kwe-na. A disease occurring in Burmah and said to 

be the same as Yaws. 

Lausesucht. See Pediculosis. 

1 Zeitschrift f. Heilkunde, 1885. 

2 Janovsky: Monatskefte f. prakt. Dermat., 1888, vii., 951. 



336 DISEASES OF THE SKIN. 

Leberflecken. See Chloasma. 
Leichdorn. See Clavus. 
Leiomyoma Cutis. See Myoma. 

Lentigo (Le 2 nt-i'-go). Synonyms : Ephelides ; (Ger.) 
Sommersprossen, Linsenflecke ; Freckles. 

Freckles are properly a species of chloasma. They 
occur as light to dark brown or even black macules, and 
are usually located upon exposed parts, especially the face 
and backs of the hands, but they may occur anywhere. 
In size they vary from a pinhead to a split pea. They 
give rise to no subjective symptoms. They usually do not 
appear before the eighth year of life, but congenital cases 
have been reported. The latter should rather be classed 
among the pigmentary nsevi. A division is sometimes 
made between those which are permanent and occur upon 
unexposed places and those which occur in summer to 
disappear in winter. To the former the name lentigo is 
given, and to the latter ephelides. The distinction is not 
worth preserving. As old age is approached freckles no 
longer form, and the old ones are apt to disappear. 

Etiology. The cause of freckles is probably an in- 
born peculiarity of the skin. It has been advanced as a 
theory of their production that they are due to the chem- 
ical action of the sun's rays upon the blood. Blondes are 
more prone to them than are brunettes. Many people 
never freckle. Symptomatically they occur as part of 
atrophoderma pigmentosum. 

Pathology. Freckles are but circumscribed deposits 
of pigment. Colin l has endeavored to show that lenti- 
gines differ from ephelides in being discrete, slightly ele- 
vated, and having their pigment in all the layers of the 
epidermis, as well as in the cutis, and in being associated 
with changes in the blood vessels of the cutis ; while 
ephelides are crowded together, their pigment is only in 
the basal layer of the epidermis, and there are no changes 
in the blood vessels. 

1 Monatshefte f. prakt. JDermat., 1891, xii., 119. 






LEPRA. 337 

Treatment. The treatment of freckles is the same as 
that of chloasma. The only prevention is to protect the 
skin from the action of the sunlight. Hardaway recom- 
mends the following : 

R. Hydrarg. ammon., \ -- %. J 

Bismuthi subnitrat. , J ' OJ > 

Ungt. aq. rosse, gj; 30 1 M. 

He also speaks highly of electrolysis for the removal of 
very black freckles. There is hardly any use in endeavor- 
ing to cure freckles occurring from the action of the sun, 
as they depart of themselves. 

Lentigo Maligna. See Atrophoderma pigmentosum. 

Leontiasis. See Leprosy. 

Lepothrix. This is a condition of the hairs of the 
axillae and scrotum which presents itself as diffuse or 
nodular incrustation of the hair, which is composed of a 
parasitic growth. The hairs are not diseased, but simply 
form a ground for the growth of the parasite. It is met 
with in those who sweat freely. Sometimes the masses 
are red. They may be removed by soap and water and 
prevented by the use of a mild antiparasitic lotion. 

Lepra (Le 2 p'-ra 3 ). Synonyms : Elephantiasis Grseco- 
rum ; Leontiasis ; Satyriasis ; Lepra Arabum ; (Fr.) La 
I^e pre ; (Ger.) Der Aussatz ; (Xorweg.) Spedalskhed ; 
Leprosy. 

A chronic, endemic, constitutional disease due to infec- 
tion by a specific bacillus ; characterized by anaesthesia, 
erythematous patches, tubercles, ulcerations, atrophies, and 
deformities according to the structures most affected ; and 
ending in death. (Fig. 38.) 

Symptoms. It is usual to describe three forms of lep- 
rosy — the tubercular, the anaesthetic, and the mixed. This 
is convenient for clinical purposes, though not absolutely 
correct, as even in the nearly pure tubercular form there 
22 



338 



DISEASES OF THE SKIN. 



is more or less anaesthesia. All forms exist in all endemic 
regions, bnt now one and now another form predominates. 
The tubercular form is the one most common in cold coun- 



Fig. 38. 




Tubercular and anesthetic leprosy 



tries, the anaesthetic in hot countries. Morrow, 2 however, 
found that in the Sandwich Islands the tubercular form 

1 From a photograph kindly loaned me by Dr. P. A. Morrow, of 
New York. 

2 New York Med. Journ., 1889, 1., 85. 



LEPRA. 339 

constituted one-half of the cases, while the anaesthetic 
form formed but one-third of them. 

Tubercular leprosy. Sometimes this form appears sud- 
denly without prodromata, but usually for days, weeks, or 
months before the disease frankly declares itself the patient 
is out of health. He feels indefinitely ill, depressed, and 
listless ; he has dyspepsia and diarrhoea ; he is weak, 
chilly, and suffers from profuse sweating. There may be 
nose-bleed. Then a remittent fever of malarial type ap- 
pears. This fever may occur without the other prodro- 
mata, and may recur with each new outbreak of tubercles. 
After a time an erythematous eruption appears upon the 
face, ears, the forearms, and thighs. It consists of purplish 
or mahogany-red, slightly raised, hyper aesthetic, smooth, 
shiny patches, of one or several inches in diameter, usually 
of oval form. The eruption may fade entirely away, to 
appear again with a fresh outbreak of fever. After some 
three to six months of the exanthem the tubercles appear, 
either upon the sites of the previous lesions, or quite in- 
dependently of them. They begin as pinhead-sized pink 
papules that enlarge to split-pea- or even to hen's-egg-size, 
yellowish-brown tubercles. If a number of these run 
together, large infiltrated patches are formed of irregular 
shape and nodular surface. Then infiltrations may also 
arise by an increased deposit of leprous material in the 
macules, for the macules themselves are formed of leprous 
material and are not simply erythematous lesions. Some- 
times the infiltrated patches that arise from the macules 
may assume ring-shapes, by clearing up in the centers. 
The tubercles are completely anaesthetic. They may come 
anywhere, but are most commonly seen in the eyebrows, 
lobes of the ears, the face generally, and upon the ex- 
tremities. They are rare on the glans penis, palms, and 
soles. The scalp is said never to be affected. The mucous 
membranes of the mouth, nose, larynx, trachea, uterus, 
and vagina are also involved, as may be the conjunctivae. 
The tubercles may undergo spontaneous involution in one 
place, while fresh outbreaks of them occur in other places. 



340 DISEASES OF THE SKIN. 

Or they may soften and break down and form leprous 
ulcers, which are indolent, sharply defined, and glazed 
over with a mucous discharge of peculiar odor. These 
may attain enormous dimensions, becoming serpiginous 
and phagedenic. When these ulcers go deep, as they may 
do on the lower extremities especially, there may take 
place spontaneous amputation of the fingers, toes, or whole 
members. This is one form of mutilating leprosy, which 
is most frequently encountered in the anaesthetic form of 
the disease. Or the tubercles may, on disappearing, leave 
atrophic spots. Their development and involution are 
always slow. The appearance of a well-developed case is 
striking. The face is deformed by the tubercles and as- 
sumes the " leonine " expression on account of the thick- 
ening of the eyebrows causing them to protrude so that 
the eyes are sunken and have a stern expression. The 
hair is wanting in the eyebrows. The immense lobes of 
the ears hang down. The lips protrude and are often 
everted. Tubercles stud the face. The forearms are 
enlarged and knobby. The hands are deformed. There 
is very commonly a discharge from the nose, a disagreeable 
odor from the mouth, and the sense of smell is lost. The 
eyesight is often lost, the voice is cracked and croaking. 
The lymphatic glands are often swollen. Happily, both 
in men and women sterility is the rule. There are com- 
monly atrophy of the testicles and loss of sexual power in 
men. The disease is steadily progressive, and death occurs 
in eight years, on an average, though the disease may last 
for many years. Crocker says 40 per cent, die of the 
disease itself, 40 per cent, die from renal or lung compli- 
cations, and the rest from diarrhoea, anaemia, or general 
marasmus. 

Ancesthetic leprosy announces its onset not by febrile 
symptoms, but by shooting, lancinating pains in the chief 
nerve-trunks, as the ulnar, median, peroneal, and saphen- 
ous. There are also pain and tenderness in various places, 
and a state of general hyperesthesia, Itching is regarded 
by Morrow as being one of the most common and charac- 



LEPRA. 



341 



teristic prodromata of this form of leprosy. There may 
also be symptoms of general malaise and digestive disturb- 
ances. A frequent early symptom is a vesicular or bul- 
lous eruption upon the fingers and toes, with at first ser- 
ous, then purulent contents. These may burst and leave 

Fi«. 39. 





Macular leprosy. 

a white, shining, anaesthetic spot, or an ulceration that 
heals with an anesthetic cicatrix. Numbness soon follows 
the hyperaesthetic state. The patient cannot grasp things 
firmly, and the consequent unskilfulness of his action may 
be the first thing to attract his attention. This shows 
muscular weakness as well as numbness. 

After some months of these prodromodal symptoms an 



342 DISEASES OF THE SKIN. 

eruption of macules similar to those of the tubercular va- 
riety appears upon the extremities, face, and back. They 
are isolated, of oval shape, hardly raised above the sur- 
face, and of a pale yellow to reddish-brown color. These 
often enlarge peripherally and clear up or become atrophic 
in the center. Sometimes instead of being oval they will 
take the form of wide streaks or of gyrate figures. They 
are often hyperaesthetic Avhen newly formed, but always 
perfectly anaesthetic when they have become atrophic, and 
even before that in cases that have lasted some little time. 
The large nerve-trunks, as that of the ulnar, are at first 
hypergesthetic, but later are anaesthetic and can be felt like 
a whip-cord, and rolled about under the finger without 
giving rise to pain. Anaesthetic areas will be found in- 
dependently of the macules, and in old cases a rather gen- 
eral anaesthesia develops so that the patient burns himself 
without noticing it. The anaesthetic areas are subject to 
change from time to time. Solitary bullae appear from 
time to time as well as urticaria-like lesions. Marked 
atrophy of the muscles of the hands and feet occurs, and 
paralysis of the extensor muscles of the second and third 
phalangeal joints. Wasted interossei muscles and per- 
manent flexion of the last phalanges of the fingers give as 
characteristic an expression to the hand in this form of 
leprosy, as the tubercles do to the facial expression of the 
tubercular form. After some ten years or so, during which 
the greater part of the cutaneous surfaces may have be- 
come studded over with white, wrinkled, hairless, atrophic 
spots, the permanent stage is reached. During these years 
painless amputation of many of the joints may have oc- 
curred by a process of dry gangrene (Lepra mutilans). 
Erysipelas may occur. The nails and hair are shed. 
Sleeplessness may prove a distressing symptom. Loss of 
sexual power and sterility are manifest late in the disease. 
There is marked anaesthesia of the soft palate, uvula, and 
pharynx. This form lasts much longer than the tubercu- 
lar form, fifteen years being an average duration. Some- 
times a fair degree of health is preserved for a much 



LEPRA. 343 

greater length of time. In most all cases more or less 
hebetude of mind is marked, becoming more pronounced 
with the duration of the disease. 

The mixed form is a combination of the symptoms of 
the two former varieties, and perhaps is the one most 
commonly met with in this country. Indeed, it is the 
rule that all tubercular cases present certain symptoms of 
the anaesthetic form, and vice versa, the variety being 
named from the prevailing lesion. 

Etiology. Up to within a few years various agencies 
were regarded as causes of leprosy, such as residence by 
the seashore, eating of putrid fish, heredity ; but in the 
light of our present knowledge there is but one cause, and 
that is contagion. The limits of this book forbid full dis- 
cussion of this interesting topic, but an incontrovertible 
argument for this view is found in the spread of the dis- 
ease in the Sandwich Islands, where, within a few years 
after its introduction, it has decimated the community. 
The contagiousness of the disease is a strong plea for the 
segregation of the lepers within our own country. 

Leprosy is seen in both sexes, though the male sex is 
more often affected. It is rare in children, and is never 
seen in infants ; a strong argument against heredity. Its 
incubation stage is very long, reaching over a period of 
years. It occurs in all countries and climates, but is en- 
demic in certain regions. It seems that a damp, cold cli- 
mate, or a hot, moist climate favors the disease. Sporadic 
cases have been reported, but careful investigation would 
doubtless show that they have been exposed to contagion. 
Vaccination has often been a carrier of contagion. 

Pathology. Constantly accumulating evidence points 
to the bacillus leprce as the disease-carrier. This has been 
found in the tubercles, the infiltrations, the lymphatic 
glands, nerves, spleen, liver, walls of the blood vessels, 
hair follicles, and sebaceous glands. It was discovered 
by Hansen in 1874, and since then has been studied by 
many pathologists. " This bacillus occurs as straight or 
very slightly curved rods, -g-^j-g- of an inch in length, and 



344 DISEASES OF THE SKIN. 

may have knob-shaped expansions at their ends or in 
their length, due to the presence of two to five spores." 
(Crocker.) Culture-experiments have for the most part 
failed, and inoculation-experiments have resulted nega- 
tively. 

Diagnosis. In a fully developed case little difficulty 
in diagnosis can arise. Sometimes lepra will need to be 
differentiated from erythema multiforme ; syphilis ; lupus ; 
morphoea ; and vitiligo. The presence of anaesthesia in 
any doubtful case will establish the diagnosis of leprosy. 
Besides this erythema runs a more acute course ; syphilis 
of the tubercular form presents redder tubercles, which 
ulcerate more readily, are grouped, and a history of syph- 
ilis is usually attainable ; the lupus tubercles are small, of 
apple-jelly color, soft, do not produce thickening of the 
eyebrows and nodular lobulation of the ears, and group 
themselves in patches in which cicatricial tissue will be 
found ; morphoea has a lardaceous appearance with a vio- 
laceous border ; vitiligo patches are more dead-white and 
sharply defined, while the skin is unaltered in texture and 
normal in sensation. 

Treatment. The best chance for recovery from leprosy 
is removal to a region where the disease is not endemic. 
This, with attention to hygiene, and a general tonic treat- 
ment, will do a great deal toward a cure. Of internal 
remedies, chaulmoogra oil holds the first rank, with an 
initial dose of three minims three times a day, and then 
gradually increased to as high a dose as the patient will 
stand. Nausea, vomiting, and diarrhoea show when this 
is reached. Fox l has cured one patient by giving nux 
vomica or strychnine up to full constitutional effects, and 
then administering chaulmoogra oil continuously. Gurjun 
oil is also highly commended in an emulsion of one part 
of the oil and three parts of lime-water, of which the dose 
is half an ounce morning and night. 

Unna claims to have cured one case with sulpho- 
ichthyolate of sodium, from six to forty-five grains a day, 
1 Post-Graduate, 1885-6, i. } 143. 



LEPRA. 345 

but others who have tried it have not had the same suc- 
cess. Salicvlate of soda, thirty grains every four hours 
till two drachms are taken ; salol in full doses ; thymol, 
forty-five to sixty grains a day ; carbolic acid up to fifteen 
grains a day, are advocated by Lutz, Besnier, and others. 
The general health of the patient should receive attention, 
and symptoms treated as they arise. H. R. Crocker 1 
has had good results in one case by weekly and then 
semi-weekly hypodermic injections of one fifth of a grain 
of calomel. 

Externally the chaulmoogra or gurjun oil may be 
rubbed in. The ulcers are to be treated upon the usual 
surgical principles. Unna 2 recommends rubbing into all 
the lesions but those on the hands and face the following : 

R. Chrysarobin., \ -- * 

Ichthyol., / aa & 

Ac. salicyl., 2 

Ungt. simpl., 100 M. 

On the face and hands he substitutes pyrogallol for the 
chrysarobin. To counteract the bad effects of the drugs 
he administers thirty drops of dilute hydrochloric acid 
during the day. For women and children he substitutes 
resorcin for the chrysarobin. To old nodes, after protect- 
ing the surrounding skin, he applies during five to seven 
days a plaster mull containing twenty to forty parts of 
salicylic acid and forty parts of creosote. 

The so-called Bhau Daji treatment 3 is said to have 
produced remarkable effects in from six to eight weeks 
after it was begun. It consists in the use of the oil 
of hydnocarpus inebrians, of which from ^10 to Sss 
is taken in the morning in boiled milk. The patient is 
also anointed with the oil. Two hours afterward the oil 
is washed off in a warm bath. He is anointed on going 
to bed. He is not allowed to eat pork, beef, or fish, nor 
to drink alcoholics, tea, or coffee. He is fed on milk, 

1 Lancet, 1896, ii., 364. 

2 Journ. Cutan. and Gen.-Urin. Dis., 1887, v., 381. 

3 Brit. Journ. Dermat., 1893, v., 203. 



346 DISEASES OF THE SKIN. 

fruit, vegetables, butter, eggs, mutton, and fowls. Roake 1 
advocates excision of the tubercles, followed by the appli- 
cation of pure carbolic acid. The thermo- or electro- 
cautery may be used to the same end. Segregation is the 
only preventive measure. 

Prognosis. The prognosis is bad, as the disease 
steadily progresses to a fatal termination unless the patient 
can be removed from the endemic region. If he can be 
removed, there is a chance of staying the disease. In 
some instances, the disease, even when the patient does 
not change his residence, pauses in its course for a long 
time ; but it will eventually again become active. 

Lepra Alphos. See Psoriasis. 

Lepra Arabum. See Elephantiasis. 

Lepre Vulgaire. See Psoriasis. 

Leprosy. See Lepra. 

Leucasmus. See Leucoderma. 

Leucoderma (Lu 2 -ko-du 5 rm/-a 3 ). Synonyms : Vitiligo ; 
Leucasmus ; Leucopathia ; Achroma ; Piebald skin. 

An acquired loss of pigment of the skin characterized 
by the formation of symmetrical white patches with con- 
vex borders surrounded by an area of hyper-pigmenta- 
tion. 

Symptoms. This is an acquired anomaly of pigmenta- 
tion, the opposite to chloasma. It is akin to albinismus, 
only that the latter is a congenital condition. It consists 
in the disappearance of the pigment of the skin in circum- 
scribed round or oval patches so that white areas are formed 
(Fig. 40). At the same time there is an accumulation of 
pigment around the areas so that there is at once a process 
of apigmentation and of hyper-pigmentation. The size-of 
the patches varies greatly. They may be no larger than a 
ten-cent piece, or of immense size. The disease most com- 
monly begins upon the neck, face, or backs of the hands, 

JBrit. Med. Journ., 1888, i., 1214. 



LEUCODEKMA. 



347 



but may begin anywhere. It is chronic. It may progress 
so as eventually to involve nearly the whole body ; or 



Fig. 40. 




Leucoderrna. (After Hyde.) 



it may become stationary ; or ; in rare cases, the skin may 
become pigmented again. It is a symmetrical disease in 



348 DISEASES OF THE SKIN. 

nearly all cases. The general health is unaffected, and 
there is no change in the sensibility of the patches. In 
some cases the white parts are unusually sensitive to expo- 
sure to the sun. When the scalp or hairy regions are 
affected the hair turns white. The disease is most evident 
in the summer on account of the increased pigmentation 
that normally occurs in the sound skin at this season. 

Etiology. The cause of the disease is obscure. All 
we can now say is that it is probably a disturbance of in- 
nervation. It is uncommon for it to occur before the tenth 
year of life, though it may do so. Adults are most fre- 
quently affected. Both sexes are subject to it. It is more 
common in the warm than in the cold countries, and is 
particularly common in negroes. Exposure to the sun 
and cold seem to be excitants in some cases. It has fol- 
lowed typhoid fever, scarlatina, and malarial fever. Wood x 
says that when mulattoes contract syphilis they become 
several shades lighter all over the body. Symptomatically 
it is seen with morphoea, Addison's disease, and alopecia 
areata. There is also a syphilitic leucoderma. I have 
had one case in a young man of eighteen years, who began 
to smoke tobacco when he was six years of age, and had 
continued to do so. He seemed to be in the best of health. 

Diagnosis. There is little difficulty in diagnosis, as 
there is no other disease in which the only symptom is a 
loss of pigment with surrounding pigmentation. In mor- 
phoea the patch may be raised, and the skin is changed in 
texture, and there is apt to be a lilac ring about it. In 
chloasma the patch itself is dark with a convex border, 
while in leucoderma the border of the pigmentation is 
concave. The concave border of the pigmentation will 
also distinguish the disease from chromophi/tosis, which 
too is scaly. The normal sensation of the patches dis- 
tinguishes them from leprosy, in which the patches are 
anaesthetic . 

Treatment. Unfortunately there is hardly anything 
that can be done in the way of treatment. Galvanism or 
iJourn. Cutan. and Ven. Dis., 1883, i., 274. 



LEUCOPLAKIA. 349 

faradism may be tried, and nerve tonics given. We must 
content ourselves with making the patches less evident by 
removing the pigment from about them by the means 
given under chloasma. Or we can stain the patches so 
that they shall be less white, as by the use of walnut 
juice. Besnier and Doyon believe that they have cured 
cases in young subjects by the prolonged use of bromide 
of potassium internally, and saline or bromo-iodide baths 
externally, with or without injections of pilocarpine. 

Leukaethiopes, a name applied to negro albinoes. 

Leucokeratose. See Leucoplakia. 

Leucopathia. See Leucoderma. 

Leucopathia Unguium. This affection consists in the 
appearance of white spots in the nail, which begin in the 
lunula, and gradually approach the free end of the nail as 
it grows forward. Sometimes these take the form of 
stripes or lines. Rarely the whole nail is affected. The 
nail-substance is otherwise unaltered. The spots are due 
to air-spaces in the nail-substance. Why these occur we 
do not know. Possibly there may be a process of fatty 
degeneration of the nerve-cells and subsequent absorption 
of the fat. (Taylor.) Or they may be caused by pressing 
back the nail-fold. They are common in the young, and 
coincident with white spots in the teeth. (Hutchinson.) 
They very often are noticed after fevers or other lowered 
conditions of health. Nothing can be done for this de- 
formity except caring for the general health of the patient 
and stopping any bad habit. 

Leucoplakia (Lir-ko-pla'-kP-a 3 ). This is a rare affec- 
tion of the mucous membrane of the tongue, lips, inside of 
the cheeks, and vulva, that has been described under the 
names of psoriasis buccalis, ichthyosis linguae, and tylosis 
lingua?. It occurs in the form of ivory-white or bluish- 
white, glistening, smooth, irregularly shaped patches upon 
the mucous membranes that may be a little elevated. 



350 DISEASES OF THE SKIN. 

They may give rise to no discomfort, or they may inter- 
fere with chewing and speaking. They may be fissured. 
There is sometimes salivation. They are caused by 
smoking, or occur in syphilis, psoriasis, lithsemia, stomachic 
or intestinal catarrh, diabetes, and disturbed nervous in- 
fluences. Sometimes they arise without assignable cause. 

They are obstinate to treatment It is very essential 
that tobacco be given up if the patient has been in the 
habit of using it. It is also necessary to address our 
remedies to the cure or relief of any lithsemic or digestive 
disorder ; and to have the teeth put and kept in good 
order. An anti-syphilitic treatment may be tried, but is 
of doubtful value. Sometimes they may be removed by 
the daily application of pure lactic acid ; or J per cent, 
solution of bichloride of mercury ; or 10 to 30 per cent. 
solution of salicylic acid ; or 1 per cent, of chromic acid ; 
or 2 to 10 per cent, of bichromate of potash ; or by 
galvano or actual cautery. 

The prognosis as to cure is not good. They not infre- 
quently take on a cancerous change. 

Lichen (Li'-ke 2 n). This term was formerly applied to 
all papular diseases, and a host of lichens were described. 
Of these, only lichen ruber, lichen planus, and lichen 
scrofulosorum have survived. 

Lichen Circinatus. See Seborrhoea. 

Lichen Moniliformis. See Lichen planus. 

Lichen Pilaris. See Keratosis pilaris. 

Lichen Plan / u 3 s. A chronic disease of the skin charac- 
terized by the eruption of smooth, waxy, angular, umbili- 
cated, red papules, that tend to form scaly, lilac-colored, 
elevated and infiltrated patches specially upon the flexor 
surfaces of the wrists and the inside of the knees. 

While the testimony from skilled observers is over- 
whelming that lichen planus papules may occur with 
lichen ruber, and while some cases of lichen ruber have 
developed after and together with lichen planus, still we 



> 



LICHEN PLANUS. 



351 



see so manv cases of the latter occurring by itself that it 
merits a special description. In this country and in En- 
gland lichen planus is far more frequent than is lichen 
acuminatum, and is regarded as a separate disease. While 
the latter occurred but 27 times in 123,746 cases, the 
former occurred 154 times in the same number of cases, 



Fig. 41. 




Lichen planus. (Fox. 1 ) 

according to the statistics of the American Dermatological 
Association. 

Symptoms. The disease begins as an eruption of small, 
purplish- or crimson-red, angular, flat, slightly raised 
papules, yarying in size from -^ to l of an inch in diam- 
eter. Their surface is smooth and shiny, "waxy-look- 
ing," and they haye a small depression in the center. 
When fully deyeloped the papules haye on them either 
gray striations, or the whole papule is gray excepting a 
rosy edge. This grayness is characteristic. The papules 
may remain discrete, and be disseminated oyer a larger or 
smaller area ; or they may arrange themselyes in rows, or 
aggregate themselyes into patches, the single papules dis- 
J G. H. Fox. The Skin Diseases of Children, N. Y. 3 1897. 



352 DISEASES OF THE SKIN. 

appearing. The single papules are not scaly, the patches 
are slightly so. The patches may be small, and if so 
there is apt to be a well-marked depression in their center, 
and their shape is round or oval. The larger patches 
have no definite shape nor depression, but are well defined 
and elevated. Characteristic single papules will be found 

Fig. 42. 





Lichen planus. (Fox.) 



scattered about in the neighborhood of the patches. The 
color of the patches is characteristic, and may be defined 
as lilac. It is an important aid in diagnosis. Both the 
papules and patches on disappearing leave behind pig- 
mented, slightly atrophic spots, which, after a time, fade 
away. It is still a moot-point as to whether the indi- 
vidual papule enlarges peripherally or not. Like those of 
psoriasis, the papules of lichen planus may appear upon 
scratched surfaces. 

The disease is most often met with upon the anterior 
surface of the wrists and forearms, and upon the inside of 
the knees, the former being the favorite location. But it 
may occur anywhere, other favorite locations being the 



LICHEN PLANUS. 353 

flanks, lower part of the abdomen, and the calves, and it 
may involve a large part of the body, though it rarely be- 
comes general. The mucous membranes of the lips and 
month are affected but rarely, and the disease then ap- 
pears as white spots difficult if not impossible of diagnosis 
without the occurrence of the typical eruption on the in- 

Fig. 43. 



Lichen ruber moniliformis. (After Taylor.) 

tegument. As a rule, there is more or less symmetry 
shown in the disposition of the efflorescences ; and pruri- 
tus, which sometimes is marked. The general health is 
often unaffected, but, on the other hand, many of the 
subjects of the disease are not in perfect condition when 
23 



354 DISEASES OF THE SKIN. 

the disease begins, and not a few others become greatly 
broken down on account of the loss of sleep and continual 
discomfort caused by the pruritus. The course of the dis- 
ease is chronic, and new outbreaks are liable to occur. 
True relapses usually do not occur when the disease is 
once cured. 

Kaposi 1 has described a unique form of this disease 
under the name of lichen ruber moniliformis, in which the 
typical lesions became transformed into keloidal nodes ar- 
ranged in lines (Fig. 43). The nodes were in some places 
as large as cherries with their bases confluent and their 
upper parts separated by furrows. The cases of this sort 
that I have seen in this country occurred in what were 
rather lichen ruber acuminatus or pityriasis rubra pilaris. 
Unna 2 describes what he names lichen obtusus, a form of 
papule midway between the acuminate and the plane. 
They are large and waxy, discrete papules, often bluish- 
white, not scaly, and but slightly itchy. A lichen verru- 
cosus and a lichen hypertrophicus have also been described. 
Pemphigoid eruptions occasionally occur as part of the 
disease. Crocker says that there is an infantile form of 
the disease in which the papules come out acutely in 
groups, acuminate at first, but soon becoming flat, angu- 
lar, and red, changing to purple. It is itchy, and tends 
to rapid recovery in a few weeks under soothing applica- 
tions. 

Etiology. We know no more about the causes of li- 
chen planus than we do about those of lichen ruber. A 
neurotic element is marked in many of the cases, and 
cases have been reported in which the papules were dis- 
tributed along the course of a nerve. 3 Nervous exhaus- 
tion, rheumatic sweating, and checking perspiration are 
given as causes. Its subjects are mostly adults. It is 
more frequent in women than in men in this country and 
in England, though in Austria the reverse obtains. 

* Vierteljalir. f. Dermat. u. Syph., 1886, xiii., 571. 
2 St. Petersburg med. Wochenschrift, 1884, i., 447. 
3 Mackenzie: Brit. Med. Journ., 1884, ii., 1077, 



LICHEX PLAXUS. 355 

Pathology. " In the plane form the process appears 
to be inflammatory, beginning usually round a sweat duct 
in the upper part of the corium, with subsequent thicken- 
ing of the rete and enlargement of the papillae by down 
growth of the inter-papillary processes." (Crocker.) The 
fact that the mucous membranes are affected is brought 
forward as an objection to the view that the process begins 
in the sweat duct. Robinson thinks that the process be- 
gins as an inflammation of the papillae and upper part of 
the corium. The form of the papule is determined by 
the shape of the so-called " skin fields." 

Diagnosis. An eruption of flat, shiny, angular, uni- 
bilicated papules of a lilac color showing grayish striations 
situated on the anterior surfaces of the wrists can be noth- 
ing but lichen planus. These same characteristics are 
diagnostic anywhere on the body, and sufficient to distin- 
guish the disease from eczema and psoriasis. Moreover, 
eczema will show a tendency to moisture, or the papules 
will undergo change ; and psoriasis will be almost sure to 
have characteristic patches upon the elbows and knees, 
covered with more abundant white and ofttimes thick 
scales. Syphilis sometimes bears a strong resemblance to 
lichen planus, but itching is less marked, its eruption is 
more polymorphous, and its color is more that of raw ham. 

Teeatmext. In the treatment of lichen planus, 
arsenic, nerve tonics, and attention to the general health 
as well as to the hygiene both of the body and mind, are 
our most reliable agents. Alkaline diuretics sometimes 
do well, as the acetate of potash. Boeck and R. W. Tay- 
lor speak well of 15-grain doses of chlorate of potash 15 
minutes after eating, followed in a quarter of an hour by 
20 drops of dilute nitric acid in a wineglass of water. 
Locally stimulants, such as tar, pyrogallol, and chrysa- 
robin will prove serviceable. Unna\s ointment, as given 
under lichen ruber acuminatus, is probably our most re- 
liable application. Touching the papules with pure car- 
bolic acid may be tried. In acute cases alkaline lotions 
will allay irritation. Thymol and naphthol may be tried 



356 DISEASES OF THE SKIN. 

as in lichen acuminata . In chronic cases Hardaway 
recommends : 

R. 



Saponis olivse prep., 




Siv; 


100 


Olei rusci, \ 
Glycerinse, j 


aa 


5J; , 


25 


01. rosmarini, 




3j ss ; 


4 


Alcoholis, 


ad 


Sviij; 


200 



M. 

well rubbed in with a piece of flannel. The patches are 
sometimes favorably affected by mercurial plaster. Some 
cases in which the skin is very irritable are best treated 
by means of prolonged simple or medicated emollient 
baths. Jacquet and other French dermatologists report 
excellent results from the use of spinal douches of water 
of varying temperature and force. 

Prognosis. The prognosis is generally favorable, 
though the disease is often very obstinate. 

Lichen Polymorphe Chronique. See Prurigo. 

Lichen Ruber Acuminatus. Though it is many years 
since Hebra first described this disease, dermatologists are 
still undecided as to many of its essential features, such 
as whether lichen planus is but a form of lichen ruber 
acuminatus, or a disease sui generis ; and as to whether 
the separate lesion of lichen ruber increases peripherally 
or not. In this country the acuminate form of the disease 
is very rare, only fifty-two cases having been reported to 
the American Dermatological Association for sixteen years 
out of a total of 204,866. While in Europe lichen planus 
is considered as only a form of lichen ruber, in this 
country and in England it is regarded by probably the 
majority of our dermatologists as a separate disease, and 
will be described as such in this book. On account of 
the diversity in the descriptions of lichen ruber, the one 
here given is taken from Hebra and Kaposi {Eehrbuch 
der HautkranMieiten, 1872). 

Lichen ruber, or lichen ruber acuminatus, is a chronic 
progressive disease of the skin marked by an eruption of 



LICHEN RUBEU ACUMINATUS. 357 

small, red, conical papules tipped with a scale. These 
tend to run together and form lines, or diffused, red, scaly, 
infiltrated patches. 

Symptoms. The disease begins as a discrete eruption 
of millet-seed-sized, slightly scaly papules, that cause but 
little itching, and therefore are accompanied by but few 
excoriations. The papules may be bright or brownish 
red, conical, hard, covered with an adherent, dry, white 
scale, and imparting, when they are present in a sufficient 
number, a rough feeling to the touch. Or they may be 
pale red, waxy, smooth, rounded, and with a small angu- 
lar depression in their center. The first outbreak may be 
scattered about the whole trunk and extremities, though 
somewhat more abundant on the flexor surfaces of the 
latter. Or it may be limited for a long time to a single 
region, such as the leg or genitals. After a time the 
eruption becomes general by the appearance of new pap- 
ules either at the periphery of the first patch, or between 
the original papules, or irregularly over all. The single 
papules never increase in size during their whole course. 
After a time the papules crowd together, and melt into 
each other and form continuous, red, infiltrated patches of 
various sizes and shapes, whose surfaces are like shagreen 
leather or covered with scales. 

This is the most common course. Sometimes, however, 
the new papules appear in manifold circular rows about the 
older ones. The older ones sink in, disappear, and leave 
a darkly pigmented depression. The thus formed patches 
are usually on the extremities. 

In a fully developed case the skin is everywhere red- 
dened, scaly, and thickened, and the movements of the 
joints are greatly interfered with so that they are held in 
a semi-flexed position. The thickening of the skin is 
specially marked on the palms, soles, fingers, and toes, 
and here rhagades are prone to form. The nails are 
thickened, uneven, brittle, broken, opaque, yellowish- 
brown ; or they are only represented by thin horny plates. 
The coarse hair of the head, axillae, and pubes is unaf- 



358 DISEASES OF THE SKIN. 

fected. Kaposi, in the third edition of his book, says 
that a defluvium capillorum takes place. 

The subjective symptoms are itching and a gradual pro- 
gressive interference with nutrition. At first the patient 
may feel quite well, but when the whole body is affected 
he falls into a general marasmus, and at last dies from 
the effects of the disease. 

So far Hebra. Subsequent observers have reported 
the occurrence of a bullous eruption in the course of the 
disease. 

Etiology. The cause of the disease is obscure. It 
affects all ages and conditions, but is most frequent in the 
male sex — about two-thirds of the cases. By many the 
disease is considered to be a neurosis. 

Diagnosis. It is needful to differentiate the disease 
from psoriasis, eczema, pityriasis rubra, pityriasis rubra 
pilaris, and lichen planus. From psoriasis it differs, when 
in the early stages, in that its papules do not enlarge into 
the large, characteristic psoriatic papules and patches ; in 
the later stages there is less scaling than in psoriasis uni- 
versalis, and more thickening of the skin ; and the palms 
and soles are far more profoundly diseased. From eczema 
it differs in that its papules neither undergo involution 
nor change into vesicles. Moreover, it does not itch so 
much, and there is never any moisture. From pityriasis 
rubra it differs in the greater thickening of the skin, and 
in its scaling, which is not in the form of thin plates or 
furfuraceous desquamation. From pityriasis rubra pilaris 
it differs in being less scaly, in affecting the flexor surfaces 
by preference, in the darker color of the eruption from the 
first, in being more itchy, and in the profound constitu- 
tional disturbance. Nevertheless the opinion is gaining 
ground that the tAVO diseases are identical. From lichen 
planus it differs in that it does not have its favorite loca- 
tions upon the flexor surface of the wrists and inside of 
the knees, in having conical and not flattened papules, in 
not forming lilac-colored angular patches, and in a more 
frequent general involvement of the skin. 



LICHEN SCROFULOSORVM. 359 

Treatment. Arsenic, by the mouth or hypodermat- 
ically is the drug upon which most reliance is placed for 
the cure of this disease. The drug must be pushed up to 
its limit of toleration and given continuously for a long 
time, and for some weeks after the disappearance of the 
eruption. The hypodermic method is very painful. The 
external treatment is by means of tar, if not too irrita- 
ting, or we may simply address ourselves to the relief of 
the itching by means of carbolic acid, one or two drachms 
to the pint of olive oil or pound of vaseline. Crocker 
speaks well of thymol or naphthol, 10 gr. to oij to the 
ounce of vaseline. Unna's l treatment has proved ser- 
viceable in many hands. He keeps the patient in bed 
between woollen blankets, and has him rubbed every 
morning and night with the following : 



R. Ungt. zinc. oxid. benzoat., ^iv ; 500 

Ac. carbolici, ^iv ; 20 

Hydrarg. bichlor., gr. ij-iv ; 0.5-1 



M. 



For the ointment of oxide of zinc, diachylon ointment 
may be substituted ; or a mixture of oil, lime-water, and 
white bole may be used instead. Where the corneous 
layer is very thick, two drachms and a half of chalk may 
be substituted for the bole. 

Prognosis. The course of the disease is essentially 
chronic. Even when a cure is effected, relapses are liable 
to occur. Hebra at first said that all cases were fatal, but 
the use of arsenic and increased experience in the treat- 
ment of the disease have greatly modified his gloomy 
prognosis. 

Lichen Scrofulosorum (L. Skro 2 f-u 2 l-os-or r u 3 m) or Scrof- 
ulosus. A disease of the skin occurring in strumous sub- 
jects, consisting in an eruption of small pale papules that 
tend to group in round or half-moon-shaped figures upon 
the abdomen, sides of the chest, and flanks. 

Symptoms. It occurs in the form of pin-point- to pin- 

1 Monatshefte f. prakt. Dermat., 1892, i., 5. 



360 DISEASES OF THE SKIN. 

head-sized, grouped, conical papules, which may be of the 
color of the skin, or pale red or iawn-colored. These 
papules occur around the hair follicles and form small 
round groups, or circles or segments of circles, upon the 
abdomen, sides of the chest, flanks, and neck in adults ; 
and upon the extremities in children. They are some- 
what scaly, but give rise to no inconvenience, so that they 
are often overlooked. In some cases the papules are so 
numerous that the groups lose their distinctive shape, and 
large surfaces are covered, giving the skin a dirty -brown 
color. Many disseminated and discrete papules are scat- 
tered over the body outside of the patches. Acne pus- 
tules may form ; and a brown pigmentation of the face 
has been observed in some cases. The papules finally 
undergo absorption, desquamate, and leave transitory yel- 
lowish pigmentation. The disease runs a chronic, slow 
course. Eczema may complicate matters. Keratosis 
pilaris is frequently well marked upon the limbs. 

Etiology. The great majority of the subjects of this 
disease present evidences of scrofula. A few are robust. 
Some are phthisical, especially the children. The disease 
is most common in childhood, and is exceedingly uncom- 
mon after the twenty-fifth year of life. It is thought by 
many authorities to be a tubercular disease, though tuber- 
cle bacilli are not found in the papules. 

Diagnosis. The disease must be differentiated from 
papular eczema, the papular syphilide, lichen ruber, a 
punctate psoriasis, and keratosis pilaris. Eczema differs 
from it in greater itching, in the brightness and rapid 
development of the papules, and in its tendency to vesicu- 
lation or moisture. The papular syphilide is of darker 
red color, much larger, and more polymorphous ; the pa- 
tient's age is usually greater, and the history and course 
of the eruption will soon decide the diagnosis. Lichen 
ruber has darker papules, which do not group in circles 
and segments of circles ; they itch, and tend to involve the 
whole surface. The patients are more often adults, and 
there is a profound constitutional disturbance. Psoriasis 



LUPOID ACN£. 361 

itches, is abundantly scaly, and its papules soon enlarge 
and form characteristic patches. Keratosis pilaris affects 
the extensor surfaces of the limbs by preference, each 
papule is plainly about a hair, and the papules do not 
group. A curled up hair will often be found in the cen- 
ter of the papule. 

Teeatmext. The persistent use of cod-liver oil both 
internally and externally will cure the disease. The 
syrup of the iodide of iron or the iodide of starch may 
be given with the oil. Good hygiene and food are valu- 
able adjuncts. For the cod-liver oil, which is disagreeable 
for external use, other oils, such as cocoa-butter, may be 
used ; or vaseline with or without oil of cade. Crocker 
recommends the addition of liq. plumb, subacetatis, Tfl.xv, 
or thymol, 5 grains to the ounce of vaseline. The disease 
tends to get well of itself. 

Lichen Simplex. See Papular eczema. 

Lichen Syphiliticus. See Papular syphilide. 

Lichen Tropicus. See Miliaria. 

Lichen Urticatus. See Urticaria. 

Lineae Albicantes. See Atrophoderma. 

Linsenflecken. See Lentigo. 

Liodermia Essentialis. See Atrophoderma pigmento- 
sum. 

Lipoma is a fatty tumor. 

Liver Spot. See Chloasma. 

Lombardian Leprosy. See Pellagra. 

Lousiness. See Pediculosis. 

Lues. See Syphilis. 

Lupoid Acne. See Acne frontalis, and Lupus miliaris. 
J. A. Fordyce 1 finds that the morbid changes begin in and 

a Jour. Cutan. and Gen.-Urin. Dis., 1894, xii., 152. 



362 DISEASES OF THE SKIN. 

about the hair follicles above the entrance of the sebaceous 
glands in acne frontalis. As the inflammatory process 
extends it involves the sebaceous glands as well as the 
superficial portion of the dernia, resulting in a necrosis 
of the pilo sebaceous system. In one case enormous 
numbers of staphylococci were found in the lymph spaces 
and free in the tissues. 

Lupus Erythematosus. (Lu'pus Er 2 -i 2 -the 2 m-a 2 t-os'u 3 s). 
Synonyms : Seborrhoea congestiva ; Lupus superficialis ; 
Lupus sebaceus ; Lupus erythematodes ; Scrofulide erythe- 
mateuse, or Erytheme centrifuge (Fr.) ; Dermatitis glan- 
dularis erythematosa (Morison) ; Ulerythema (Unna). 

This is a chronic disease of the skin, occurring in vari- 
ously sized, slightly elevated, scaly, red patches which show 
a strong tendency to the production of atrophic scars. 

Symptoms. There are two varieties commonly de- 
scribed, namely, the circumscribed or discoid, and the 
diffuse, or disseminated, or aggregated. To these some 
of the English writers add a third, the telangiectic. 

The circumscribed or discoid form is the one most often 
met with. It occurs generally on the face, specially upon 
the sides of the nose and the cheeks, the scalp, and the 
ears ; more rarely upon the hands and feet ; and still more 
rarely on other parts of the body. It begins by the ap- 
pearance of several isolated or grouped red spots slightly 
elevated, of pinhead to split-pea size, with a thin adherent 
scale upon them. Some of these spots may be depressed 
in the center. When the scale is removed there will be 
found upon its under side a delicate projection formed by 
a plug of sebaceous matter that dipped down into the 
mouth of the sebaceous gland. The mouth of the gland 
will be found patulous. These spots increase in size by 
peripheral extension to form disc-shaped figures of varying 
size ; neighboring ones will coalesce, and thus patches 
will be formed, also covered with the fine grayish or white 
adherent scales. Now when the scale is raised a number 
of the characteristic prolongations will be found on its 
lower side. The margins of the patches are slightly 



LUPUS ERYTHEMATOSUS. 363 

raised, but the middle parts undergo involution, are lower 
than the margins, and after a time are apt to become 
cicatricial, the skin being atrophied. The scar-tissue thus 
formed is thin, delicate, and white, never puckered or 
deforming. 

The color of the patches is red, but of a peculiar hue 
that is characteristic, and perhaps can be best defined as 
violaceous. There is never any moisture connected with 
the disease. Burning or itching may or may not be pres- 
sent. The patches are of indefinite duration — months or 
years. At times they disappear of themselves, and do not 
leave scars, but the rule is that scars are left. The ex- 
tent of the disease varies greatly, as well as the shape of 
the patches. The greater part of the face may be in- 
volved, or there may be only a single patch. Usually 
the eruption is symmetrical. A characteristic location for 
the disease is upon the back and sides of the nose and the 
contiguous parts of the cheeks, forming what has been 
fancifully called a butterfly, the ridge of the nose repre- 
senting the back of the animal, and the cheeks its wings. 
Sometimes gyrate figures are formed. The mucous mem- 
branes and the vermilion border of the lips may be af- 
fected, presenting patches with punctate excoriations of 
red color, or spotted with grayish masses of exudation and 
superficial cicatrices. Occurring upon the scalp it leads 
to permanent loss of hair, and the same may be said of it 
as it occurs on other hairy parts. The disease may be- 
come stationary after a time. Eelapses are liable to oc- 
cur. The general health is unaffected. 

The diffuse or disseminate form is a more acute process, 
and exceedingly rare in this country. In it the patches 
may appear suddenly, or slowly develop. They are from 
pinhead to finger-nail size, slightly elevated, reddish- 
brown, hyperaemic, and hard ; they pale under pressure, 
and are attended with heat and burning. In this stage 
they resemble an urticaria, or the papular stage of eczema. 
There may be twenty to a hundred or more of them, 
crowded together upon the face and scattered over the 



364 DISEASES OF THE SKIN. 

body. Many of them may disappear in a few days with- 
out leaving any trace, while others will remain and become 
characteristic patches of lupus erythematosus with de- 
pressed cicatrices. The individual lesions do not increase 
in size, and the patches are formed by aggregations of 
single lesions. The eruption may be accompanied by a 
high degree of inflammation, exudation, and crusting, or 
even by bulla?. There may be deep, painful subcutaneous 
tumors in the joints and glands at first, over which char- 
acteristic patches will form. In some acute cases the de- 
velopment of the patches is accompanied by fever, osteo- 
copic pains, and nocturnal headaches, and in some cases 
the patient will pass into a typhoid condition and die of 
some lung complication. Or there may be a persistent in- 
flammation of the face, erysipelas perstans, which may 
lead through a typhoid state to death. There may also 
be swelling of the parotid glands, and of various lym- 
phatic glands. In some cases the disease bears a close 
resemblance to chilblain. 

The telangiectic form occurs, according to Crocker, as a 
persistent circumscribed redness, which close inspection 
shows to be due to dilated vessels, and is commonly lo- 
cated symmetrically upon both cheeks. Upon pinching 
up the skin it will be found to be markedly thickened. 
Some few comedones may be present, There is no des- 
quamation. 

Etiology. About two-thirds of the cases occur in 
women. It seldom occurs before puberty, though Kaposi 
has seen a case in a child of three years. Beyond these 
facts we know but little of its etiology. The French re- 
gard it as a scrofulous affection. Nothing suggesting its 
relation to a tuberculous process has ever been found in 
the skin. It is true that some few cases have reacted to 
tuberculin injections, but that is no proof of its tubercu- 
lar origin. On account of not a few patients having 
other symptoms of a general tuberculosis, or giving a his- 
tory of tuberculosis in other members of their family, 
Besnier regards lupus erythematosus as allied to lupus 



LUPUS ERYTHEMATOSUS. 365 



vulgaris, and as a species of tuberculosis of the skin. 
Crocker suggests a feeble circulation, and prolonged ex- 
posure to great cold or heat as possible causes. It would 
also seem that those who are subjects of seborrhoea are 
predisposed to the disease. 

Pathology. In spite of much careful study it is still 
undetermined whether the disease is inflammatory or not. 
O. H. Holder 1 believes that the process is due to embo- 
lism of the small arteries, arising either on account of an 
alteration in the blood due to a toxin, or to some change 
in the walls of the vessels, or to a thrombus brought from 
some distant part. In the majority of cases the earliest 
manifestation of the disease is an infiltration of round 
cells in the middle of the lower zone of the corium, the 
sebaceous glands and hair follicles being secondarily in- 
volved. The cicatricial scarring is the result of atrophic 
processes. 

Diagnosis. The disease must be differentiated from 
lupus vulgaris, eczema, rosacea, psoriasis, and syphilis. A 
typical case occurring upon the face in the form of red 
patches, with fine cicatrices in the center, and covered 
with a delicate white or grayish adherent scale, from the 
underside of which are a number of projections, offers no 
difficulty in diagnosis. Lupus vulgaris differs from lupus 
erythematosus in occurring before puberty, in showing no 
disposition to symmetry, in the presence of apple-jelly 
tubercles, in being a deep-seated disease, and in leading to 
far more disfiguring cicatrices. Eczema never leaves scars, 
is prone to exudation, itches, its scales do not show pro- 
longations from the underside, and its patches undergo 
more rapid and varied changes. Psoriasis will be pretty 
sure to show characteristic patches covered with thick 
scales, and never causes scarring or leads to permanent 
loss of hair. Rosacea is largely composed of dilated 
blood vessels, occupies the middle third of the face, often 
presents superficial pustules, does not leave scars, and is 
subject to frequent exacerbations. In syphilis a history of 
^our. Cutan. and Gen.-Urin. Dis., 1897, xv., 207, 



366 DISEASES OF THE SKIN. 

other lesions will be obtainable, there will be more evi- 
dent infiltration, and the course of the lesions will be 
more rapid. The disseminate form of the disease would 
be very difficult of diagnosis at first, but as soon as char- 
acteristic patches form the difficulty would be removed. 

When lupus erythematosus occurs upon the scalp it 
causes a bald spot that may be mistaken for alopecia areata, 
but differs from it in its irregular shape, in the signs of 
inflammation in it, and in the cicatricial condition of the 
scalp it leaves. A microscopical examination of the hairs 
from about a patch will decide as between lupus erythema- 
tosus and favus or ringworm. 

Treatment. Little beyond the care of the general 
condition of the patient upon general principles can be 
done for lupus erythematosus in the way of internal medi- 
cation. McCall Anderson advocates the use of iodide of 
starch, made by triturating twenty-four grains of iodine 
with a little water, and gradually adding one ounce of 
starch, rubbing them well together until a deep-blue color 
of the mass is struck. Of this a heaped teaspoonful, in- 
creased gradually, may be given three times a day in water 
or gruel. Iodide of potassium is also commended, as are 
phosphorus and salicylate of soda. 

Sometimes in the early stages alkaline washes, such as 
lotions of zinc or lead, may be used. Or one composed of 



R. 



Zinci sulphat, , \ 
Potassii sulphurat. , J 


aa 5j; 


3 


Alcohol., 


5«j; 


10 


Aquse rosse, 


acl giv; 


100 



M. 



as in acne and rosacea. Green soap or prepared olive 
soap, or its tincture, may be used in more chronic cases. 
This is often serviceable for the disease as it attacks the 
eyelids. The affected parts are to be well rubbed with it, 
using a piece of flannel. The process is to be repeated 
every few days. If the reaction is too great, a little oil 
or a glycerin lotion may be applied. Crocker advocates 
the addition of one or two drachms of the oil of cade to 



LUPUS ERYTHEMATOSUS. 367 

the ounce of the tincture of green soap. Carbolic acid, 
pure, applied to the patches, often acts admirably. It 
turns them white at first. The application is to be re- 
peated as soon as the crust falls. Fowler's solution 5j in 
distilled water Sj, and spirits of chloroform 2 drops, ap- 
plied externally in the morning and evening is sometimes 
efficacious. Resorcin, 50 per cent, aqueous solution, ap- 
plied once or twice a day until decided reaction takes place, 
and then cold cream or calamin lotion used until the reac- 
tion subsides, has done better in my hands in chronic 
cases than any other plan I have tried. The resorcin 
solution must be repeated when the reaction has subsided. 
Pyrogallic acid, 10 per cent, in ointment, sometimes does 
well ; as also chloracetic acid ; oil of cade ; solution of 
naphthol, 1 per cent.; resorcin 3 to 10 per cent, strength 
in solution or ointment ; tincture of iodine or iodide of 
glycerin ; caustic potash, one part to six or twelve of 
water. Hydronaphthol plaster and resorcin plasters of 
10 to 20 per cent, strength, and mercurial plaster are often 
excellent when persisted in. Sulphur or ichthyol in oint- 
ment or paste does well in some cases. Thilanin some- 
times does well. All cases should be carefully watched 
that the reaction from our remedies does not go too far. 
If these superficial caustics do not cure, resort may be 
had to linear scarifications, making a series of cross-hatch- 
ings, taking care not to go very deep. The bleeding is 
to be checked by pressure and the application of carbolic 
acid, two drachms to the ounce. Limited surfaces must 
be taken at a time. Electrolysis by means of multiple 
punctures will sometimes give brilliant results. Some- 
times running the needle across the patch, making a num- 
ber of parallel insertions, will have a good effect. Erasion 
with the curette, galvano or Paquelin cautery, and strong 
escharotics, such as the acid nitrate of mercury, may have 
to be used in very obstinate cases, but not till all other 
means are exhausted, as they are apt to leave deep scars. 
Progxosis. The prognosis should be guarded, as the 
disease is a most obstinate one, and prone to relapses. A 



368 DISEASES OF THE SKIN. 

cure may, however, be effected by patient perseverance. 
It is wise always to tell our patients that scars are liable 
to be left, not only by the treatment employed, but by the 
disease itself. An accidental attack of facial erysipelas 
cured one case under my observation. The discoid form 
has little effect upon the health of the patient, but the dis- 
seminated variety not infrequently ends fatally. 

Lupus Exedens. See Lupus vulgaris. This term is 
sometimes applied by surgeons to epithelioma. 

Lupus Exfoliativus. See Lupus vulgaris. 

Lupus Exulcerans. See Lupus vulgaris. 

Lupus Hypertrophicus. See Lupus vulgaris. 

Lupus Miliaris or Lupoid or Adenoid Acne is a rare 
disease of the skin that occurs upon the cheeks in the form 
of discrete, pinhead-sized, deep-red, slightly raised papules, 
which do not tend to suppurate. Sometimes the papules 
will disappear, leaving a pit behind. The papules must 
be treated by very much the same remedies as are useful 
in lupus, such as by salicylic acid plaster, or acid nitrate 
of mercury. 

Lupus Pernio. This disease affects the uncovered parts, 
hands, face, and specially the ears, nose, and upper lip. 
It is ill-defined, and extends over large surfaces. It is 
marked by cyanosis, telangiectasis, infiltration of the skin, 
diffuse tumefaction, Assuring of the skin, and superficial 
vesiculation. Slight ulcerations form that become cov- 
ered with crusts and last a long time. The old patches 
are studded with irregular cicatrices. It is a chronic dis- 
ease with no subjective symptoms. It occurs in lym- 
phatic subjects, and is distinct from the other varieties of 
lupus. 1 

Lupus Sclereux. See Tuberculosis verrucosa cutis. 
Lupus Sebaceus. See Lupus erythematosus. 
1 Tenneson. Atlas de Musee de l'hopital, St. Louis, p. 135. 



LUPUS VULGARIS. 369 

Lupus Superficialis. See Lupus erythematosus. 
Lupus Tuberculosus. See Lupus vulgaris. 
Lupus Verrucosus. See Lupus vulgaris. 
Lupus Vorax. See Lupus vulgaris. 

Lupus Vulgaris (L. Yu 3 l-ga-ri 2 s). Synonyms : Besides 
those given above, which merely describe certain stages or 
forms of the disease, and are quite unnecessary to be re- 
membered, we have : Noli me tangere ; Herpes esthio- 
menos ; (Fr.) Dartre rongeante, Scrofulide tuberculeuse, 
Esthiomene ; (Ger.) Fressende Flechte. 

This is a chronic neoplastic disease of the skin due to 
its invasion by the tubercle bacillus, and characterized by 
one or more brownish-red papules, tubercles, or infiltrated 
patches, that tend either to absorption or ulceration, and 
always leave scars. 

Symptoms. Lupus vulgaris usually begins in child- 
hood and upon the face ; the cheek and nose being the 
parts most usually affected. The initial lesion is a dark- 
red or brown pin-point- to pinhead-sized papule, which 
may be on a level with the skin, depressed below, or 
raised above it. There may be but a single lesion, but 
more usually there are a few of them either grouped or 
scattered. After a time slightly scaly patches will form 
by the coalescence of the lesions which have enlarged, 
into brownish-red, semi-translucent, smooth, shiny tu- 
bercles, or by the development of new lesions between 
the old ones. The shape of the patches is irregular. 
Rarely they are ring-shaped. The size of the patches 
varies greatly, but they are always elevated above the 
surface of the skin, of a dark-red color, and studded with 
the little brownish-red papules, or so-called tubercles. 
The appearance of these tubercles has been likened by 
Hutchinson to that of apple-jelly. There may be but 
one patch, or the whole face may be more or less covered 
with a number of them. Symmetry is not a feature of 
the disease, often only one side of the face being affected. 
24 



370 DISEASES OF THE SKIN. 

Sometimes two or more patches will coalesce at their 
borders, their centers will fade out, or rather become 
atrophic, and a gyrate patch will form, creeping over 
the skin with a well-marked, elevated, red border. The 
center of all the patches is lower than the border, and 
eventually is atrophic. The course of the disease is slow 
and chronic, and the fate of the patches varies greatly. 
For months or years they may remain absolutely quiet, 
and then show signs of activity by new lesions appearing 
about the edges of the patches or in the scar-tissue. The 
patches may entirely disappear, leaving a fine, smooth 
cicatrix ; this is rare without treatment. Or they may 
break down and form ulcers, which are irregularly rounded 
in shape, shallow, with easily bleeding floors, and a mod- 
erate amount of purulent secretion that dries into a crust. 
This is the so-called lupus exulcerans, and is not very 
frequent in this country according to my experience. 
Sometimes upon this ulcerated surface papillary or warty 
growths will spring up, the so-called lupus papillomatosus 
or verrucosus. Sometimes the infiltration of the patch is 
unusually great, and then we have lupus hypertrophicus. 
Most commonly we have a non-ulcerated, exceedingly 
chronic infiltrated patch with areas of cicatricial tissue 
scattered through it. When the disease attacks the end 
of the nose it will cause it to shrink up and convert it 
into cicatricial tissue. When the ear is diseased it also 
shrinks up so as to be half the size it was originally. 
These changes are due either to ulceration or to the 
gradual absorption of the lupus tubercles that they all 
undergo. 

While the face is the site of predilection of lupus, it may 
also occur upon any part of the skin of the body, as well 
as upon the mucous membranes. In this latter situation 
it is most often secondary to the disease elsewhere, still it 
is often primary. Thus Bender 1 found that 30 t 3 q- per 
cent, of all his lupus cases began in the nasal mucous 
membrane. Pontoppidan also found the origin of the dis- 
iVierteljahr. f. Derm, und Syph., 1888, xv., 891. 



LUPUS VULGARIS. 371 

ease to be the nasal mucous membrane in many cases. In 
the nose it frequently leads to perforation of the septum 
and sometimes causes great deformity of the nose, but it 
does not attack the bones. All other mucous membranes 
may be attacked ; the rectum and vagina being least often 
affected. Upon mucous membranes we do not see the same 
tubercles as on the skin, but papillary excrescences which 
form patches. They may be absorbed or ulcerate. The 
conjunctivae may be involved primarily or secondarily. 
Epithelial cancer has developed in very rare instances 
upon the lupoid tissue itself, more commonly upon the 
scar tissue left by the lupus. Whenever it develops as a 
sequela of lupus its course is more rapid and its prognosis 
far more grave than is usually the case. Erysipelas is 
a not infrequent complication of lupus, and is sometimes 
curative in its action. Lupus of the extremities is often 
followed by permanent deformities and disabilities, and 
sometimes by tubercular lymphangitis. Implication of 
the lymphatic glands is exceptional in lupus, and then 
only in advanced cases. 

Etiology. Lupus has long been regarded as a mani- 
festation of scrofula. It is now demonstrated that it 
is a tubercular disease. It should be placed under the 
division of tuberculosis cutis, but usage makes it advis- 
able to consider it by itself. Many patients with lupus 
are plainly strumous ; many, 55^ per cent, of SachV 
cases, are either tuberculous themselves or have a decided 
history of the occurrence of phthisis in their family. 
The phthisical history is far less pronounced in this coun- 
try than it is in Europe. It is no uncommon thing for 
several members of the same family to have lupus. It 
is probable that we could find a close connection between 
lupus and infection with the tuberculous virus in all cases, 
were it practicable to do so. Another evidence of its tu- 
bercular origin is found in the nearly uniform reaction of 
lupus to tuberculin. It is much more frequent in females 
than in males, about 62 per cent, being in females accord- 
1 Vierteljahr. f. Derm, mid Sypli., 1888, xiii., 241. 



372 DISEASES OF THE SKIN. 

ing to Block's and Sach's statistics. It begins in more 
than half the cases before the fifteenth year. It may begin 
as early as the second year. It is almost always a disease 
of youth. 

Pathology. The pathology of lupus has been studied 
by many competent investigators. As their results do not 
altogether agree, this is no place to discuss them. " It is a 
neoplasm of the granuloma class, and consists of a small- 
cell infiltration which begins in the deep part of ths co- 
rium, and from thence gradually invades all the other skin 
structures/' says Crocker. The tubercle bacillus is found 
in the tissues, though but sparsely. Inoculations have 
not always been successful, but in a goodly number of 
cases the inoculations have been followed by general tu- 
berculosis, so as to warrant our beli3f in the tubercular 
nature of the disease. It has been suggested that as the 
bacilli are present in but a small number, the irritation of 
the tissues is due to the toxines produced by them. 

Diagnosis. Lupus is most commonly confounded with 
a tubercular or gummous syphilicle. It may have to be 
differentiated from a scrofuloclerm originating in a caseous 
gland, from an epithelioma, lupus erythematosus, and 
possibly lepra. From syphilis it is diagnosticated by the 
presence of the characteristic apple-jelly tubercles ; by its 
slow course ; by its history ; by the absence of all other 
signs of syphilis ; by its little tendency to ulceration ; by 
the superficial character of its ulcers and their slight 
crusting ; and by its sparing the bones. If there is still 
any doubt, appeal may be made to the effect of treatment 
by means of the iodide of potassium and mercury, which 
will have no effect upon the lupus. As the scrofuloderm 
is another manifestation of the tubercular diathesis and 
amenable to the same treatment as that of lupus, its dif- 
ferentiation is not so important. It, however, will begin 
about a caseous and broken-down lymphatic gland, will 
probably have sinuses, and no characteristic tubercles. 
An epithelioma begins usually after the thirty-fifth year ; 
has no tubercles ; and forms a deep ulcer with raised, 



LUPUS VULGARIS. 



373 



hard, waxy edges crossed with dilated blood vessels. The 
diagnosis from lupus erythematosus is given in the preced- 
ing section. Leprosy presents large tubercles which are 
anaesthetic, and this at once decides in its favor. 

Treatment. As lupus is a tubercular disease, and 
sometimes is followed by tuberculosis of the lungs, care 
must be given to the general health of the patient, and he 
must be placed in the best possible hygienic surroundings. 
His diet should be nutritious, and cod-liver oil, iodine, and 
iron should be given. But external treatment is of the 
greatest importance, and the disease must be gotten rid of 
root and branch. If a single diseased cell remains, the 
disease is sure to return. To effect its destruction surgi- 
cal procedures had best be resorted to. The whole patch 
or patches may be scraped out with the dermal curette, 
and this followed by a 25 or 30 per cent, pyrogallol oint- 

Fig. 44. 




Scarifying-knife. 

ment for a week or ten days, and that in turn by the 
mercurial plaster for another equal term. The pyrogallol 
will cause free suppuration and destroy the cells left be- 
hind by the curette. A second or third course may be 
necessary. Piffard prefers to touch the base left after 
curetting with the galvano-cautery at a red heat. The 
wound is then to be packed with absorbent cotton. After 
about ten to fourteen days the crust and cotton will fall 
off and leave a soft, smooth, pliable cicatrix. Multiple 
scarifications have proved of great use. They may be 
made with a many-bladed instrument constructed for the 
purpose, or with a scalpel, or a knife shaped like a 
butcher's cleaver (Fig. 44). They must go deep enough 
to penetrate all the softened tissue, but not to wound the 
sound parts. The resistance offered by the healthy tis- 
sues will be sufficient guide for this. The scarifications 



374 DISEASES OF THE SKIN. 

should be so made as to divide the tissues into little 
squares, thus : 




They may be repeated in five or six days, and need no 
after-treatment. This is Vidal's method. The individual 
tubercles may be bored out with Morris's double-screw in- 
strument, or with dental burrs and hooks as proposed by 
Dr. George H. Fox. Pare carbolic acid may be intro- 
duced into the little holes so left to insure the further de- 
struction of the disease. The galvano or Paquelin cautery 
may be employed to destroy the disease. This will re- 
quire the administration of an anaesthetic, while the former 
procedures do not require it, or at most anything more 
than local anaesthesia by means of cocaine. Multiple 
punctures by means of the galvano- or thermo-cautery at 
sombre red heat at 1 mm. distance for small patches and 
linear scarifications with cautery knife for large ones, fol- 
lowed by emplast. vigo, and repeated once a week, is Bes- 
nier's method. Electrolysis in multiple punctures or by 
passing the needle through the patch or by means of a 
flat metallic button, is a useful mode of treatment. The 
current must measure 3 to 5 milliamperes, and it must be 
continued for five minutes, when the button is used. 
Auspitz recommends puncturing the patches in many 
places with a steel point dipped in carbolic acid. Small 
patches may be excised. 

These surgical procedures have largely superseded the 
use of caustics, though the latter are valuable and may be 
used when the patient fears an operation. Arsenic may 
be employed in the form of a paste such as Hebra's modi- 
fication of Cosine's Paste : 



R. Ac. arsenios., gr. x ; 2' 

Hydrarg. sulphured rubri, 3J '■> 12 50 

Ungt. aq. rosse, gj ; 100J M. 



LUPUS VULGARIS. 375 

which is to be spread on lint or linen, applied evenly, and 
bound down firmly. It is to be left on for twenty-four 
hours, then removed and reapplied till ulceration is set up. 
It is painful. Vienna paste, of equal parts of caustic 
potash and unslacked lime ; or a chloride of zinc paste 
may be used, such as 1 part of zinc to 3 parts of starch. 
Both are painful. Many think highly of boring into the 
patch with the solid nitrate of silver stick. Salicylic 
acid, 20 to 25 per cent., in plaster or plaster muslin 
changed once or twice a day is good. It is well to com- 
bine creosote with the salicylic acid two parts to one, to 
allay the pain caused by the acid. The local application 
of bichloride of mercury in solution (gr. j to oj) to ulcer- 
ated forms, and in ointment to non-ulcerated forms, is 
commended by White and others. 

Unna 1 recommends painting with pure carbolic acid for 
from two to four days. He has also had good results 
with a salve muslin containing 1 per cent, of bichloride 
of mercury, 20 per cent, of carbolic acid, and 36 per 
cent, of oxide of zinc. He 2 has also recommended the 
following procedure : Little sticks of hard wood are sharp- 
ened and then soaked for several days in a solution of 

R . Hydrarg. bichlor. , 1 

Ac. salicylici, 10 

Etheris sulph., 25 

01. olivffi, 100 M. 

These sticks are forced into each tubercle, cut off close to 
the skin, and covered with gutta percha or carbolized 
mercurial plaster. After two days the plaster is removed, 
leaving a surface covered with a thin layer of pus. The 
holes made by the sticks are enlarged and the sticks lie 
loose in them. The sticks are removed, the surface asep- 
tically cleansed, the holes filled with a powder of 

R. Hydrarg. bichlor., 01 

Magnes. carbonat., 10 

Ac. salicylici, 5| 

Cocain. muriat., 5 M. 

1 Monatshefte f. prakt. Derm., 1891, xii., 341. 
2 Ibid., 1895, xxi., 281. 



376 DISEASES OF THE SKIN. 

which is blown on with a powder-blower and worked in 
by the fingers or with a wooden spatula. It is again cov- 
ered with the plaster for twenty-four hours, when the 
procedure is repeated for another day. The subsequent 
treatment is by pyrogallic acid. 

Neither tuberculin nor tuberculin TR has proved as 
valuable as it promised. Only very few cases have been 
reported as cured. The inconvenience, depression, and 
sometimes fatal results from these remedies render them 
unfit for general use. 

Prognosis. The prognosis should always be guarded. 
Relapses after any plan are too often seen. A scar must 
result both from the disease and its treatment. The pos- 
sibility of the development of a general tuberculosis must 
also be borne in mind, although most patients preserve 
throughout the course of the disease a robust state of 
health. 

Lymphangiectasis (LPmf-am-jP-e^'-ta^sPs). Varices 
of the dermal lymphatics may be superficial or deep ; and 
affect the trunk, the meshes, or the lacunae, though most 
commonly all parts of the vessels are diseased. When 
they are superficial they form ampullary swellings at the 
surface of the skin which may be isolated or agglomer- 
ated. In size they vary from the size of a millet-seed to 
that of a pea, or larger. In color they vary with that of 
the skin. They break more or less easily and discharge 
the lymphatic fluid. If deep, they can be more readily 
felt than seen, or form upon the surface of the skin iso- 
lated or associated raised cords which run a more or less 
tortuous course. After a time these also break and dis- 
charge lymph. 

Hallopeau and Goupil l describe under this title a dis- 
ease that they believe to be of tubercular origin, and that 
appears about a bony prominence of the extremities as a 
diffuse tumefaction, or a cushion-like elevation resembling 
varicose vein tumors. They eventually open and dis- 

^nn. de derm, et syph., 1890, i., 957. 



LYMPHANGIOMA. 377 

charge pure lymph, or lymph mixed with pus. Fresh 
tumors arise in the course of the lymphatics in an ascend- 
ing series ; also gummy nodes. The affected limb is swol- 
len, indurated, and of more or less sombre red. The 
prognosis is grave, and the proper treatment undetermined. 

Lymphangioma (Li 2 mf-a 2 n-ji 2 -o'-ma 3 ), also called Lym- 
phangiectasis, Lymphangiectodes, Lupus Lymphaticus, and 
Lymphorrhagica Pachydermia, is an exceedingly rare dis- 
ease. It consists, according to Crocker, in a number of 
minute, deep-seated vesicles, closely crowded together in 
irregularly outlined groups of from one-third to one-quar- 

Fig. 45. 




Lymphangioma, (Epstein. 1 ) 

ter of an inch in size. These groups are arranged irreg- 
ularly with healthy skin between them, or a few scat- 
tered vesicles in the otherwise healthy skin. They are 
usually confined to a single small area. The vesicles are 
deep-seated with thick walls, some of them almost warty- 
looking. They are pin-point to hemp -seed size, colorless 

1 By permission from Jour. Cutan. and Gen.-ITrin. Dis., 1892, x., 214. 



378 DISEASES OF THE SKIN. 

or straw-colored, or pinkish, and contain a clear fluid. 
Some have vascular striae or tufts over them, others red 
clots, others contain extravasated blood. 

They run a chronic, non-inflammatory course, spread- 
ing slowly at the periphery, and tending to relapse if re- 
moved. Most of the few cases have occurred in males 
and began in early childhood. 

The disease is of lymphatic origin, and the main feature 
is dilated lymphatic vessels. 

The treatment consists in destruction by caustics, ex- 
cision, or electrolysis, but relapses are liable to occur. 

A number of other rare affections of the lymphatics 
have been named lymphangioma. The present state of 
our knowledge in regard to them is by no means exact. 
One variety is named by Kaposi ; 

Lymphangioma Tuberosum Multiplex. This is a still 
more rare disease than lymphangioma, and consisted, in 
Kaposi's case, in the appearance all over the trunk and 
neck of hundreds of lentil-sized, rounded, brownish-red, 
smooth, glistening, disseminated, flat, or elevated tuber- 
cles. They were firm and elastic, slightly painful, and 
upon some of them were dilated blood vessels. One or 
two other cases of the same kind have been reported by 
others. By some this disease is regarded as a species of 
benign cystic epithelioma. 

Lymphoderma Perniciosa. See Mycosis fungoides. 

Lymphosarcoma. See Sarcoma. 

Maculae et Striae Atrophicae. See Atrophoderma stria- 
tum et maculacum. 

Maculae Caeruleae. See Pediculosis corporis. 

Madura Foot. See Fungous Foot of India. 

Mai de la Rosa. See Pellagra. 

Mai Rosso. See Pellagra. 

Maladie des Vagabonds. See Pediculosis. 



MILIARIA. 379 

Malignant Papillary Dermatitis. See Paget' s Disease. 

Malignant Pustule. See Pustula maligna. 

Malingering. See Feigned Eruptions. 

Malleus. See Equinia. 

Mamillaris Maligna. See Paget' s Disease. 

Mask. See Chloasma. 

Measles. See Morbilli. 

Medicinal Eruptions. See Dermatitis medicamentosa. 

Melanoderma. See Chloasma. 

Melasma. See Chloasma. 

Melanosarcoma. See Sarcoma. 

Melanosis Lenticularis Progressiva. See Atropho- 
derma pigmentosum. 

Melitagra. See Pustular eczema. 

Mentagra. See Sycosis. 

Micro sporon furfur is the parasite of chromophytosis, 
which see. 

Miliaria (Mi 2 l-i 2 -a'-ri 2 -a 3 ). Synonyms : Sudamina ; 
Lichen tropicus ; (Ger.) Frieselauschlag ; Prickly heat. 

This is a disease of the sweat glands due to excessive 
sweating, which may or may not be inflammatory, and is 
characterized by an eruption of discrete papules, vesicles, 
or pustules. Several varieties are described, but it is 
enough to distinguish two forms, namely, sudamina and 
lichen tropicus. 

Symptoms. Sudamina, also called miliaria crystallina, 
is the form that is met with during the course of febrile 
diseases, and occurs as an eruption of an immense num- 
ber of small, closely crowded, but discrete, bright, pearly 
vesicles entirely without inflammation or subjective symp- 
toms. They are most abundant on the trunk, especially 



380 DISEASES OF THE SKIN. 

upon its anterior plane, but may occur anywhere. After 
lasting a few days they are absorbed and disappear by 
drying up, possibly with some scaling, or they may rup- 
ture and dry up. 

Lichen tropicus is very commonly seen in this country 
during warm weather. It may consist in an eruption of 
pin-point, bright-red papules (miliaria papulosa) ; or of 
very small vesicles upon an inflamed skin (miliaria rubra) ; 
or the eruption may be a composite one of papules inter- 
spersed with vesicles and pustules. Whichever form it 
may assume the lesions are present in great number, and 
closely crowded together, though not aggregated. It may 
involve the whole surface of the body, but is most com- 
mon on covered parts, and specially upon the trunk. The 
eruption is apt to become better or worse according to 
the changes in the temperature of the atmosphere. The 
disease may last in this way throughout the warm weather. 
It is no uncommon thing for furuncles to form, and even 
cutaneous abscesses. Itching, prickling, and burning are 
always annoying accompaniments. If the skin is much 
scratched, eczema may complicate the disease. The old 
nurse's " red gum," the strophulus of older writers, is a 
miliaria. Kaposi regards the disease as an eczema. 

Etiology. The cause of sudamina is retained sweat, 
owing, probably, to epithelium clogging up the sweat 
pores when sweating is stopped on account of the fever. 
Lichen tropicus is due to congestion about the sweat pores 
and irritation of the skin when profuse sweating is in- 
duced by too warm clothing and hot weather. It is also 
suggested that checking a profuse sweat may cause it. It 
is seen most commonly in babies and fat people. It is 
noticeable in this city (New York) that the children who 
live near the river front and are a good deal in the salt 
water escape the disease, while it is very common in the 
rest of the tenement-house population. 

Diagnosis. Sudamina differs from vesicular eczema by 
its sudden occurrence during a febrile process ; by being 
non-inflammatory ; by its vesicles not breaking down ; 



MILIUM. 381 

and by not itching. Lichen tropicus differs from eczema 
by the minuteness of its papules ; by its sudden appear- 
ance ; by not forming patches which are moist ; by hav- 
ing a high atmospheric temperature as an evident etiolog- 
ical factor, and by the tingling rather than the itching of 
the eruption. 

Treatment. Sudamina needs no treatment, as with 
the subsidence of the fever it gets well of itself. Lichen 
tropicus requires attention to the diet, cutting off the meat 
in children, and lessening its amount in adults. Cooling 
drinks and the administration of gentle saline laxatives 
are also advisable. Locally, bathing in salt water or 
alkaline lotions, and subsequent powdering of the skin, 
conjoined with wearing light clothing, and not using too 
warm bedcovers, will relieve and ofttimes cure the trouble. 

Miliary Fever, or the sweating sickness, is an epidemic 
disease accompanied by profuse sweating and miliaria. 
The epidemics have occurred most often in France. 

Milium (Mi 2 l-i 2 -u 3 m). Synonyms : Grutum ; Strophu- 
lus albidus ; Acne albida ; Tuberculum sebaceum. 

Symptoms. These are small pinhead- to split-pea- 
sized, firm, whitish, or yellowish, slightly elevated pap- 
ules that occur usually upon the face. They are spherical 
in shape, and slowly increase in size up to a certain point, 
when they remain stationary. When incised and pressed 
upon laterally a small, white, round, oval, or lobulated 
mass emerges. They give rise to no subjective sensation. 
While their most common site is the face below the eyes, 
they may occur anywhere on the face ; and also upon 
the border of the lips, the penis, and scrotum. In this 
latter situation they are more decidedly yellow in color, 
flat, and often attain the size of a small bean. Along the 
corona glandis they are sometimes very thickly strewn. 
On the genitals of women their most frequent site is the 
labia minora. There may be but one or two, or a score of 
them. Occurring in the eyelids they are called chalazion. 
When they undergo calcareous degeneration (an infrequent 



382 DISEASES OF THE SKIN. 

occurrence), they form cutaneous calculi Comedones are 
often present at the same time with milia. Any part of 
the body may be affected. 

Etiology. Milia occur chiefly in infants and young 
adults, and sometimes follow other diseases of the skin, 
such as pemphigus, erysipelas, or those in which destruc- 
tive processes have taken place and cicatrices formed. 
They are often congenital. 

Pathology. They are supposed to be due to retained 
secretion on account of the upper layers of the stratum 
corneum growing over the openings of the sebaceous 
glands, or to a non-development of the glands. Robin- 
son thinks that some of them are due to " miscarried em- 
bryonic epithelium from a hair follicle or from the rete," 
while those " following pemphigus, erysipelas, syphilis, 
and lupus consist of fatty epithelium and cholesterine, 
the epithelium being often arranged in concentric layers 
around a central fat-nucleus." 

Diagnosis. They must be differentiated from xan- 
thoma. The latter are more of a lemon-yellow or buff 
color, and cannot be squeezed out when incised. Mollus- 
cum is sometimes mistaken for milium, but it is more 
prominent and hemispherical, and has a central punctum, 
out of which its contents can be squeezed without punc- 
turing its top. 

Treatment. The treatment consists in pricking the 
top of the papule and pressing out its contents. To make 
sure of the destruction of the growth a drop of carbolic 
acid or iodine may be introduced into the cavity re- 
maining. Hardaway advocates electrolysis as being the 
speediest and best treatment. If operative procedures 
are inadmissible, the skin may be caused to exfoliate by 
the use of green soap or salicylic acid, when the milia 
will be destroyed. 

Milk Crust. See Eczema. 

Mitesser. See Comedo. 

Mole. See Nsevus. 



MOLLUSCUM CONTAGIOSUM. 



383 



Molluscum Cholesterique. See Xanthoma. 

Molluscum C ontagio sum (Mo 2 l-lu 3 sk r u 3 m ko 2 n-ta-ji 2 -os r 
u s m). Synonyms : Molluscum epitheliale, seu sebaceum, 
sen verrucosum, seu sessile ; Epithelioma contagiosum ; 
(Fr.) Acne varioliforme, Ecdermoptosis. 

Fig. 46. 




Molluscum. (After Allen.) 



Symptoms. This is a contagious disease of the skin 
that occurs in most cases upon the face and in children, 
and is characterized by the appearance of one or more 
rounded pearly white or pinkish discrete tumors, varying 
in size from a pinhead to large pea (Fig. 46). These 
tumors are waxy or opaque, and on top are slightly flat- 



384 DISEASES OF THE SKIN. 

tened, and show an umbilication or small depression, out 
of which the soft cheesy contents of the tumors can be 
squeezed. These tumors are at first very small, but 
gradually grow until they attain a certain size, when they 
may remain unchanged for an indefinite period, or they 
may become inflamed, break down of themselves, dis- 
charge their contents, and disappear either without leav- 
ing any trace or with a very slight scar. There are not 
infrequently scores of these tumors to be found on the 
same subject. They are commonly sessile, but may be- 
come more or less pedunculated. The genitalia, breast, 
and scalp are affected next to the face in point of fre- 
quency, while the tumors may occur anywhere but on the 
palms and soles. 

Etiology. Children are far more often affected than 
adults. If adults are affected, it will usually be found 
that they are in attendance upon children who have mol- 
luscum. The bad hygienic conditions under which poor 
people live seem to predispose to the affection, as it is 
rare to meet with it among the well-to-do. There is lit- 
tle doubt that the disease is contagious. Though inocu- 
lation-experiments have failed in most instances, still 
there have been a few cases in which they have been suc- 
cessful. In the spring of 1891 a child with molluscum 
contagiosum came into my service in Randall's Island 
Hospital, and within a few weeks, no attempt being made 
to destroy the tumors, there were six cases in the wards. 

Pathology. The true pathological anatomy of these 
growths has not been settled, but the old idea that they 
spring from the sebaceous glands is no longer entertained. 
The rete seems to be the starting-point of the disease. 
One of the most characteristic features of the disease is 
the so-called " molluscum corpuscle," which is but a 
changed epithelial cell (Fig. 47). These appear, under 
the microscope, as large, ovoid, lustrous bodies, without 
nuclei, some being either wholly or partly contained in 
an epidermic envelope, and some being entirely uncov- 
ered. Several parasites have been declared to be the 



MOLLUSCUM PENDULUM. 



385 



cause of the disease by different investigators, the latest 
candidates being the psorosperm of Darier in 1889, and 
the gregarine of Neisser in 1888. Torok 1 declares these 
to be merely artificial products of the methods used, and 
is sure that the disease is not due to a parasite. 



Fig. 4/ 




Molluscum corpuscles. (After Kaposi.) 

Diagnosis. The appearance of the disease is so char- 
acteristic as to be diagnostic. It is most apt to be con- 
fused with milium, but if it is remembered that a milium 
has no central depression, while a molluscum has, the 
confusion will exist no longer. If they are taken for the 
vesico-pustules of variola, a scarcely probable occurrence, 
pricking their tops will at once show that they are not 
pustules, and if they are watched for a day or so it will 
be found that they remain unchanged. 

Treatment. The speediest way of getting rid of the 
tumors is to scrape them off with the curette. To insure 
their not returning it is advisable to touch the base of each 
tumor with a drop of carbolic acid, or a stronger acid. Or 
it is sufficient to make a small slit in the top of the tumor 
with a scalpel, and squeeze out the contents, and touch the 
base with carbolic acid. 

Molluscum Epitheliale. See Molluscum contagiosum. 

Mulluscum Fibrosum. See Fibroma. 

Molluscum Pendulum. See Fibroma. 



25 



1 Monatshefte f. prakt. Dermat., ,1890, 



149. 



386 DISEASES OF THE SKIN. 

Molluscum Sebaceum. See Molluscum contagiosum. 
Molluscum Verrucosum. See Molluscum contagiosum. 
Monilethrix. See Trichorrhexis nodosa. 

Morbilli (Mo 2 rb-i 2/ -li). Synonyms : Rubeola ; measles. 

This is one of the contagious exanthemata. Its stage 
of incubation is from eight to twenty-one days, usually 
from ten to twelve days. It is characterized by pro- 
dromata of marked catarrhal symptoms, such as con- 
junctivitis, coryza, and bronchial inflammation, more or 
less fever, and constitutional disturbance ; and then, 
on about the third day, an eruption of small, red, flat 
papules that rapidly enlarge, and uniting with others 
form mulberry-colored little patches often of a crescentic 
shape, with areas of sound skin between. H. Koplik 1 
calls attention to the fact that one or two days before the 
eruption appears on the skin there will be found on the 
buccal mucous membrane and on the inside of the lips 
small irregular bright red spots with a minute bluish 
speck in the center. The eruption begins on the face and 
neck, spreading downward, from which it covers the 
whole body in about a day and a half. The fever begins 
to decrease on the second day of the eruption. The rash 
begins to disappear by the third or fourth day, and is gone 
by the ninth day. Furfuraceous desquamation follows 
the subsidence of the exanthem. Sometimes it is so 
slight as to be hardly noticeable, and it is never so 
marked as in scarlatina. 

Diagnosis. The only dermatoses with which measles 
is apt to be confounded are an erythema, rubeola or Ger- 
man measles, variola, and the macular syphilide. But 
the catarrhal symptoms ; the regular progression of the 
eruption from above downward ; and the crescentic patchy 
arrangement and dark color of the lesions are sufficient to 
differentiate it. In erythema we may have some constitu- 
tional disturbance, but it is of short duration ; the eruption 
is more pronounced on the trunk and extremities, and 
] Arch. Pediatrics, Dec, 1896 r 



MORPHCEA. 387 

shows no order of progression ; the color of the eruption 
is a brighter red ; there is an absence of crescentic arrange- 
ment ; and very often an accompanying urethritis will 
suggest the ingestion of some of the balsams as a cause 
of the trouble. In rubeola there is not so much constitu- 
tional disturbance, less catarrhal complications, and a pro- 
nounced swelling of the glands of the neck. The erup- 
tion is usually a remarkably fine papular one, not so 
patchy as in measles. Variola in its early stage is some- 
times difficult to diagnose from measles. Backache is 
usually a marked symptom in variola, its papules are 
smaller, harder, and more shot-like, and lack the crescen- 
tic arrangement of measles. The subsequent course of 
the disease is, of course, very different from that of 
measles. The erythematous syphilkle affects the sides of 
the chest and the abdomen more than the face ; the rash 
lasts for weeks after any possible fever has passed ; its 
lesions have no definite arrangement and come out in suc- 
cessive crops, so that at the same time there will be pres- 
ent lesions of different age, and staining of the skin from 
those that have gone. 

Treatment is purely symptomatic. 

Morbus Elephas. See Elephantiasis. 

Morbus Maculosus Werlhofii. See Purpura. 

Morbus Pedicularis. See Pediculosis. 

Morphcea (iVfcrrf-e'-a 3 ). Synonyms : Keloid of Addison ; 
Circumscribed scleroderma . 

A chronic, circumscribed hardening of the skin, form- 
ing an oval or irregularly shaped, smooth, lardaceous, 
yellowish patch, looking as if mortised into the skin, and 
tending to spontaneous recovery. 

Symptoms. This is one of the rarer forms of skin 
disease. It is a circumscribed scleroderma. It occurs 
either as circumscribed, variously sized, oval or irregularly 
shaped patches ; or in the form of bands. The most com- 
mon is the patchy form. It begins as a congested, red, 



388 DISEASES OF THE SKIN. 

rosy, or lilac macule, which enlarges, pales in the center, 
becomes hardened, and assumes the form of a character- 
istic patch of the disease. This patch looks like a piece 
of old ivory or of lard set in the skin, being of a yellowish- 
white color. The color may be pinkish, yellow, brown, or 
even black. The skin over the patch is usually smooth, 
and easily pinched up. It may be wrinkled, or eroded in 
the center. It may be level with the surface of the skin, 
or raised above it, or sunken below it. Around it is a lilac 
border due to dilated vessels. When the patch is pinched 
between the fingers it feels firm, like leather. There may 
be but a single patch or a number of them. As a rule, 
the disease is unilateral. After a varying length of time 
it may disappear spontaneously, although it may remain 
for a number of years. There are usually no subjective 
symptoms, and the disease remains unchanged until it 
disappears. In some cases it enlarges by new patches 
developing at the periphery of the old one and uniting 
with it. Exceptionally there may be some itching or 
pain, and ulceration may occur. Sensation is generally 
preserved. The band form is usually single, and may 
form a depressed sulcus or a raised ridge, looking much 
like a cicatrix. In addition to the bands there may be 
atrophic spots. 

The most common locations of morphoea are anywhere 
on the trunk, but specially on the breasts ; on the head 
and face in the parts supplied by the fifth nerve, and on 
the limbs. It is not infrequently associated with other 
nervous phenomena, and may occur along the course of a 
nerve, like zoster. Nettleship 1 has reported a case in the 
region of the first and second divisions of the fifth nerve 
with paralysis of the intraocular branches of the third 
nerve, which in time had associated with it hemiatrophy 
of the whole of the left side of the head. There is no 
disturbance of the general health. The secretion of sweat 
over the patches may be normal, lessened, or absent. 
When the disease disappears it may leave no trace of 
1 Trans. Clin. Soc. Lond., 1882-3, xvi., 199. 



MORPHCEA. 389 

itself, or it may be followed by pigmentation or even 
permanent atrophy, not only of the skin, but also of the 
muscles. A form of leprosy has been wrongly named 
morphcea. 

Etiology. The disease is a neurosis that occurs at all 
ages after the second year, but is uncommon after middle 
life. The victims of it are often neurotic. Prolonged 
worry or anxiety seems to predispose to it, and in some 
cases external local irritation seems to excite it. It is 
said that the band-form is most frequently seen in children, 
and that females are more often affected than males. 

Pathology. Owing to some defect in innervation 
cell-exudation occurs round the vessels, narrowing their 
lumen and obstructing their blood-flow, and leading to 
thrombosis, and sometimes to a real rupture and effusion. 
Each atrophic spot near a groAving patch is the base of a 
cone from which the blood-supply is cut off, the violet 
zone being due to collateral hyperemia round an anaemic 
area. (Crocker.) 

Diagnosis. Keloid may be mistaken for morphcea, 
but it has claw-like processes ; is more vascular and 
harder ; and lacks the old ivory color and the lilac sur- 
rounding zone. Some forms of ancesthetic leprosy have 
been spoken of as morphcea, but they are markedly anaes- 
thetic, and this will be sufficient for diagnosis. Leuco- 
derma is a pigment-change only, the skin being otherwise 
unchanged. 

Treatment. Unfortunately there is little or nothing 
to be done for the disease beyond attention to the general 
health of the patient. Arsenic may be of some benefit. 
Galvanism is perhaps the only local means that gives any 
promise of benefit, and that is but a feeble one. Further 
methods of treatment will be found under Scleroderma. 

Prognosis. We can tell our patient that there is a 
strong probability that the disease will be recovered from 
in time, but we should be careful about giving a positively 
favorable prognosis. 



390 DISEASES OF THE SKIN. 

Morpion is a name for the pubic louse. 

Morvan's Disease is a disease of the spinal cord which 
causes profound cutaneous lesions, such as ulceration, 
bulla?, and fissures of the palmar side of the hands and 
fingers, and paronychia and necrosis of several phalanges. 
It is allied to, if not identical with, syringomyelia, which 
see. 

Morve. See Equinia. 

Moth Patch. See Chloasma. 

Mother's Mark. See Nsevus. 

Multiple Fungoid Papillomatus Tumors. See Mycosis 
fungoides. 

Myasis Externa Dermatosa is a dermatitis due to the 
penetration of the skin by certain kinds of flies, which lay 
their eggs under the skin. These subsequently hatch out 
and give rise to the dermatitis. 

Mycetoma. See Fungous foot of India. 

Mycosis Framb03si0d.es. See Dermatitis papillaris ca- 
pillitii. 

Mycosis Fungoides (Mi-ko'-si 2 s fu 3 n-go 2 -i'-dez). Syno- 
nyms : Inflammatory fungoid neoplasm ; Multiple fungoid 
papillomatous tumors ; Fibroma fungoides ; Lymphadenie 
cutanee ; Granuloma fungoides ; Eczema hypertrophicum 
seu tuberosum ; Ulcerative scrofuloderma ; Lymphoder- 
mia perniciosa ; Sarcomatosis generalis ; Multiple sarcoma 
cutis ; Fungoid dermatitis ; Beerschwamahnliche multiple 
Papillargeschwulste der Haut. 

A chronic progressive disease of the skin, characterized 
by the appearance, with or without an antecedent erythe- 
matous or eczematous stage, of fungating tumors, that 
tend to break down and ulcerate. It leads, through 
m irasmus, to death. 

Symptoms. The many names that have been applied 
to this rare disease testify to the uncertainty of our knowl- 



MYCOSIS FUNGOIDES. 391 

edge of its proper place in the classification of skin dis- 
eases. It assumes so many forms that it is impossible in 
our limited space to give a complete picture of the disease. 
In some cases the first thing noticed is what appears to be 
a simple eczema, erythema, urticaria, or psoriasis in vari- 
ously sized patches, and accompanied by marked pruritus. 
These lesions occur anywhere, and constitute the first 
stage of the disease. After some months, or two or three 
years or more, the patches become raised, glistening, and 
infiltrated, more deeply red, and pea-sized papules form. 
These disappear, and new ones form. This is the second 
stage, and may last months or years. Then the charac- 
teristic tumors form either by the papules enlarging and 
coalescing, or as tumors at once rising out of the sound 
skin, without antecedent erythematous stage. The tumors 
are oval, hemispherical, or irregular in shape, sharply 
defined, sometimes slightly pedunculated. They are of 
bright-red, bluish-red, or dark-red color. They are some- 
times hard and elastic, sometimes soft and succulent, The 
epidermis over them is tense, thin, and glistening. They 
may be absorbed and disappear, new ones appearing ; or 
they may become necrotic and ulcerate. In size they vary 
from that of a pea to that of the fist. At first they occur only 
on the trunk, later they come anywhere, and involve even 
the mucous membrane of the mouth. The itching and 
pain continue well into the tumor-stage, when they lessen. 
The lymphatic glands enlarge painlessly. The hair falls 
from over the tumors. The general health of the patient 
is undisturbed for a long time, but at last a general maras- 
mus sets in and the patient dies, usually from an uncon- 
trollable diarrhoea or some complication on the side of the 
lungs. There lias been but one case of recovery reported. 
Etiology. The majority of the cases have been women 
over thirty years old. The disease is held not to be con- 
tagious. Blanc l found in one case that there was a marked 
reduction in the white blood corpuscles, their proportion 
to red being 1 to 130, instead of 1 to 350 or 500. This is 
^ourn. Cutan. and Gen.-Urin. Dis., 1888, vi., 256. 



392 DISEASES OF THE SKIN. 

about all that is known of the etiology of the disease. 
While much study has been given to the pathology of the 
affection there is no agreement among pathologists as to 
its essential nature. 

Diagnosis. The diagnosis of the disease in its early 
erythematous stage is very difficult, and probably cannot 
be made with certainty. There is something peculiar in 
the sharply circumscribed outline, and the chronicity of 
the eczematous patches, and an unusual location and per- 
tinacity about the psoriatic patches that would suggest the 
possibility of mycosis fungoides. When the tumors de- 
velop, and the capricious manner of their coming and 
going is observed, the diagnosis is more evident. 

Treatment. Thus far nothing has been found to stay 
the course of the disease, except that Kobner reports a 
cure of a case by means of hypodermic injections of 
arsenic. A general tonic treatment is always indicated. 
Locally, pyrogallol ; ichthyol ; mercurial ointment ; in- 
jections of carbolic acid ; resorcin, and camphorated 
naphthol have been used and may be tried. The itching 
is most rebellious to treatment. The tumors, when not in 
great numbers, may be cut out, though the operation is 
of doubtful utility. The ulcerations that result from 
breaking down of the tumors must be treated on surgical 
principles. 

Mycosis Microsporina. See Chromophytosis. 

Myoma (Mi-o r -ma 3 ). Like most of the tumors, so this 
one concerns the surgeon more than the dermatologist. 
Myomata may be single or multiple. They are composed 
of muscular fibers, and vary in size from a split pea to an 
orange. They are painful on pressure, and sometimes 
spontaneously. They are pink, reel, or normal in color, 
disseminated, or aggregated into patches, though still re- 
taining their individuality. The epidermis over them is 
unchanged. The single tumors may be sessile or pedun- 
culated, and may attain the size of an orange. They have 
their seat most often on the female breasts, and on the 



MYXCEDEMA. 393 

genitalia of both sexes. If they contain a good deal of 
fibrous tissue, they are called fi.br o-myoma ; if they con- 
tain large blood vessels, they form angio-myoma ; or, if 
the lymphatics are involved, we have lymphangio-my&ma. 
Excision is the only thing. that can be done for them. 

Myoma Telangiectodes. See Myoma (Angio-myoma). 

Myxoedema (Mi 2 x-e 2 d-e'-ma). This is a constitutional 
disease with cutaneous symptoms. The skin becomes 
waxy pale ; yellowish ; shining in some places, dull and 
earthy-looking in others ; it is dry, scaly, exfoliating on 
the extremities, sometimes ulcerated, and verrucose on the 
lower limbs. The fingers and toes are sometimes livid. 
There is partial or general alopecia, and deformity and 
fragility of the nails. There is a general oedematous 
swelling of the whole integument as well as of the mucous 
membranes, and this oedema does not pit on pressure. 
The swelling is most marked in the face. The skin about 
the eyes becomes puffed up so as almost to close the eyes. 
Cushions of fat fill the supraclavicular spaces. There is 
atrophy of the thyroid gland. The patient's intellectual 
faculties become dulled, the speech is slow, and the gait 
unsteady. 

The disease affects women far more often than men, and 
involves all parts of the body. There is an enfeeblement 
of mind, and a great lowering of the senses of touch, taste, 
and smell ; a torpidity of movement and of the digestive 
functions. It ends fatally either by marasmus or by com- 
plications on the side of the internal organs. 

The diagnosis in the early stage is difficult ; when fully 
developed it could hardly be taken for anything else. 
The cause of the disease is unknown. 

Treatment. All the symptoms are removed by the 
use of thyroid extract or powder, improvement being 
rapid. When the treatment is stopped the patients after 
a time lapse into their former state, so that the adminis- 
tration of the thyroid has to be more or less continuous. 



394 DISEASES OF THE SKIN. 

Nsevus (Ne'-vu 3 s). A nsevus, strictly speaking, is a 
congenital mark or growth in the skin, which may be 
either pigmentary or vascular. 

Naevus Araneus. See Telangiectasis. 

Nsevus Lupus. See Angioma serpiginosum. 

Naevus Pigmentosus. Synonyms : Nsevus spilus ; Nsevus 
pilosus ; Nsevus verrucosus ; Nsevus lipomatodes ; (Ger.) 
Fleckenmal, Pignientmal, Linsenmal ; Pigmentary mole ; 
Mother's mark. 

Fig. 48. 




Naevus lipomatodes. 

A congenital, circumscribed hyper-pigmentation of the 
skin, often accompanied by a growth of coarse hair, and 
hypertrophy of the connective and fatty tissues. 

Symptoms. These growths are closely allied to lentigo 
and chloasma, as a hypertrophy of pigment is a promi- 
nent feature of them. When they consist of pigment 
only, and are not raised above the surface of the skin, 



N^JVUS PIGMENTOSUS. 395 

they are called ncevus spilus. When besides the pigment 
there is a hypertrophy of the connective tissue, and they 
are raised and uneven, the name ncevus verrucosus is ap- 
plied to them ; or ncevus lipomatocles if they are soft and 
contain fatty tissue ; if hair grows from either form, then 
we speak of ncevus pilosus. In color they vary from a 
light to dark brown or black. In size they vary from a 
split pea to an area large enough to cover the whole back. 
Most commonly they are of small size. They may be 
located anywhere, though most often on the face, neck, 
and back. There may be but one or two, or hundreds of 
them. They may have no special distribution, or they 
may occur in streaks or bands. They may be unilateral 
or bilateral, and sometimes symmetrical. If hair is in 
them, it is coarse and stiff, and generally darker than that 
of the head. Sometimes large hairy moles bear a strong 
resemblance to the fur of animals. They grow in pro- 
portion to the growth of the individual, and cease grow- 
ing when he has attained his growth. They are usually 
congenital, but may be acquired, and are liable to undergo 
malignant change in advanced life. They give rise to 
no subjective symptoms. They are permanent growths. 
They rarely disappear of themselves. 

Etiology. To account for the appearance of these 
malformations we have only the theory of nerve-influence, 
and that is by no means satisfactory. Their popular name 
of mother's mark shows that the popular superstition 
agrees with the scientific theory. We can simply regard 
them as anomalies. 

Diagnosis. Moles differ from lentigo in being con- 
genital and permanent, and in a hypertrophy of connect- 
ive tissue and a growth of hair being connected with 
them. The difference between hairy moles and hypertri- 
chosis is in the substratum ; in the latter the underlying 
skin is otherwise normal. 

Treatment. We can destroy these growths and leave 
behind but little scar. If there is but a single pigmen- 
tary mole, it may be cut out. In this case it will leave a 



396 DISEASES OF THE SKIN. 

linear scar. It is generally better to destroy the growth 
by touching it over carefully with nitric or glacial acetic 
acid. This is done by stippling, as it were, making a row 
of dots in this fashion — 



Electrolysis by multiple puncture, or by transfixing the 
mole in various directions, is a sure and speedy way. J. 
Brault l recommends tattooing them with a solution of 30 
parts of chloride of zinc and 40 parts of sterilized water. 
The eschar falls in five to ten days. It may be necessary 
to repeat the process. Hairy moles are best destroyed by 
electrolysis as in superfluous hair, only here a coarser 
needle must be used, as we are not so particular about a 
little scarring. The warty growths may be removed by a 
curette. 

Naevus TJnius Lateris. This form of naevus has been 
described as a variety of ichthyosis hystrix, but it should 
be regarded as a form of naevus pigmentosus. It is also 
called nerve naevus, naevus verrucosus, neuropathic papil- 
loma, and papilloma neuroticum. It occurs as streaks of 
raised, pigmented, sometimes warty, sometimes papilloma- 
tous growths. They seem at times to follow nerve or 
vascular tracts, or perhaps the cleavage-lines of the skin. 
They may be unilateral and confined to one region, or 
they may be bilateral and on several regions. They may 
be congenital or develop in the first few years of life or 
later. They tend to enlarge until early adult life. The 
treatment is the same as that for naevus pigmentosus. 

Naevus Vascularis. Synonyms : Naevus vasculosus seu 
sanguineus ; Angioma ; (Ger.) Feuermal, Gefassmal ; (Fr.) 
Tache de feu, Tache vasculaire ; Port-wine mark ; Birth- 
mark ; Claret stain. 

Symptoms. These are composed mainly of vascular 
tissue, and are congenital or appear during the first month 
1 Ann. de derm, et syph., 1895, vi., 33. 



X.EVUS VASCULARIS. 397 

of life. They are usually single, but may be multiple. 
They vary greatly in size, shape, and color, but all possess 
one feature in common — they pale under pressure. They 
may be pinhead spots not raised above the surface of the 
skin, or they may form large, erectile, elevated, pulsating 
tumors, or they may spread out so as to involve a large 
area. They may be pink, bright-red, dark-red, or even 
purple in color. "When on the face they become more 
pronounced on crying, coughing, and the like. They 
may disappear spontaneously ; increase in size during 
a few months or years ; or, most commonly, remain un- 
changed. According to their size they have received va- 
rious names. The small, flat, or scarcely raised nsevus 
composed of capillaries is called ncevus simplex or capil- 
lary nsevus. This is the form very often seen in children. 
It is not infrequent for it to disappear of itself after a 
while, either leaving no trace, or a delicate atrophic scar. 
When it is so large as to form a patch as big as the hand 
or larger, it is called ncevus flammeus or port-wine mark. 
The surface of this form is often uneven, and studded 
with small, erectile, vascular tumors, or, may be, pigmen- 
tary moles. It often becomes dark purple after exposure 
to cold. The large, erectile, pulsating tumors are called 
ncevus tuberosus, angioma cavernosum, venous ncevus. They 
differ very much from the other forms in appearance and 
formation. Their surface is uneven and lobulated. This 
form is apt to increase in size, and may attain enormous 
dimensions. 

Xsevi may occur anywhere on the body, but are most 
frequent on the head and face. They may also occur 
upon the mucous membranes primarily or secondarily. 
The back, nates, pudenda, and lower limbs are said by 
Crocker to be the most common sites of the cavernous 
form. All forms of naevi may be hardly perceptible at 
birth, but become gradually more evident afterward. 

Etiology axd Pathology. Vascular naevi are prob- 
ably always congenital malformations, though their ap- 
pearance upon the skin may be retarded for some time. 



398 DISEASES OF THE SKIN. 

The simple capillary nsevi, which include the port-wine 
marks, are simply an increase in number and size of the 
capillaries. In the venous naevi we have also a new 
growth of connective tissue forming a raeshwork, and they 
are supplied directly by an artery without the interposi- 
tion of capillaries. Women are more prone to them than 
are men. 

Diagnosis. There can be no difficulty in diagnosis, 
excepting that a nsevus may be taken for a telangiectasis. 
This error would be of little consequence, since the latter 
is simply an acquired nsevus, and differs chiefly in having a 
central red point from which the dilated capillaries radiate. 

Treatment. Electrolysis is the best means for de- 
stroying the vast majority of these growths. The best 
way to use it in capillary naevi and port-wine marks is by 
making multiple punctures in parallel rows, perpendicu- 
larly to the skin and down through its entire thickness. 
To expedite matters one may use either a circle of needles 
set in a handle, or a row of three needles. The negative 
pole is to be connected with the needle-holder, and the 
operation is to be conducted in the same way as in remov- 
ing superfluous hair. By this method it is possible to 
destroy small nsevi entirely, and to diminish very much 
the unsightly appearance of large port-wine marks. As 
electrolysis necessarily destroys the skin, we must leave a 
scar. But this is less conspicuous than the nsevus, and if 
the operation is carefully done the scar is soft, smooth, 
and pliable. There is also much less danger of a deform- 
ing scar from the use of a single needle than from a 
group of them. Therefore this method is preferable, 
though more tedious. The punctures must not be made 
close together ; at least a sixteenth of an inch should be 
left between them. After the nsevus has been carefully 
gone over, it should be left alone for a couple of weeks or 
more for the full effect of the operation, to be seen. It 
can be gone over again, and another interval of time al- 
lowed, and so on till the growth is destroyed as much as 
possible. 



NjEVUS VASCULARIS. 399 

Besides electrolysis we may use multiple scarifications 
obliquely to the skin. Or we may use the ethylate of 
sodium freshly prepared and applied to the absolutely dry 
skin, using a brush or glass rod. To avoid scarring only 
a small part of the naevus must be attacked at a time. 
A crust will form, which must be left to come away of 
itself. Fuming nitric acid or the acid nitrate of mercury 
may be stippled over the growth. Or vaccination may 
be performed over it. Or multiple punctures may be 
made by means of a steel needle dipped in nitric or car- 
bolic acid. Marshall Hall advocates breaking up the 
naevus by introducing a cataract-needle close to the edge 
of the growth, pushing it across to the opposite side, then 
nearly withdrawing it, and again pushing it in at a little 
distance from the first puncture. But electrolysis is the 
best and most controllable method. 

For cavernous naevus we may use electrolysis also, but 
here we pass the needle obliquely into the skin in the 
hope of striking the deep vessels. It is well, sometimes, 
to pass the needle from the edge deep under the naevus 
and clear through to the other side, let the current pass 
for half a minute, partially withdraw the needle, and 
again push it in another direction. Some prefer introduc- 
ing two needles, connected each with one pole of the bat- 
tery, in opposite directions. A platinum or gold needle 
must be used with the positive pole. Excision may be 
performed, but sometimes this gives rise to alarming hem- 
orrhage. Multiple punctures with a red-hot steel shoe- 
maker's awl, or the point of a Paquelin or galvano-cautery 
heated to a dull red, are other good methods of treatment. 
It has been proposed to use a metallic plate perforated 
with a number of holes with which to exercise strong 
pressure upon the nsevus while the galvano-cautery is in- 
troduced through the holes. Injections of carbolic acid, 
perchloride of iron, alcohol, and the like, are effectual, 
but dangerous methods. Setons are not used as much as 
formerly. Compression by an elastic bandage is at times 
curative when the naavi are located over bony prominences. 



400 DISEASES OF THE SKIN. 

As many capillary nsevi in children disappear in time 
it is advisable not to interfere with them at once, content- 
ing ourselves with painting them with collodion and wait- 
ing until the child is old enough to desire their removal. 
Of course, if they are very unsightly we cannot wait, 
nor should Ave temporize with cavernous nsevi. In chil- 
dren one works most comfortably by using an anaesthetic, 
but it is not absolutely necessary. Keloidal scars may be 
an unfortunate result of treatment in some cases. 

Prognosis. The prognosis should be guarded, and 
the cases carefully watched. All nsevi may increase in 
size, though very many remain stationary. 

Nsevus Verrucosus. See Ichthyosis hystrix and nsevus 
unius lateris. 

Narbengeschwulst. See Keloid. 

Nerven Nsevi. See nsevus unius lateris. 

Nesselausschlag. See Urticaria. 

Nettlerash. See Urticaria. 

Neuralgia Cutis. See Dermatalgia. 

Neuroma Cutis is an exceedinglv rare disease of which 
but few cases have been reported. Neuromata are small, 
flat, pinkish, or pale-red firm tumors firmly imbedded in 
the skin. They are painful spontaneously and on pres- 
sure. The pain may be paroxysmal in character. They 
are relievable by surgical interference with the nerve. 

Neuropathic Papilloma. See Ichthyosis hystrix. 

Nodositas Crinium. See Trichorrhexis nodosa. 

Nodosites Non-erythemateuses des Arthritiques. Brocq 
applies this name to cutaneous and subcutaneous tumors 
that he has met with in connection with the gouty dia- 
thesis. They are of two varieties. The first one he calls 
Ephemeral cutaneous nodules. They occur upon the fore- 
head and form ill-defined elevations of the skin, of small 
pea to hazelnut size, and entirely painless. They are 



(EDEMA CUTIS. 401 

movable with the skin, though sometimes they are adher- 
ent. They appear first during the night and disappear 
within twenty-four hours. 

The second variety is the subcutaneous rheumatismal 
nodule. It forms a small tumor resembling a gumma. 
The skin slides freely over it in most cases. The color of 
the skin is unchanged. It is firm and elastic to the touch. 
Generally such tumors are painful on pressure, at times 
spontaneously. In size they vary from a pea to an 
almond, and they are sharply defined. They may remain 
for days or weeks, when they disappear, leaving no trace. 
They often come in successive outbreaks. Their seat of 
predilection is about the joints, and upon the fibrous tis- 
sues that cover the superficial bones. They are generally 
discrete, and frequently very numerous. Their appear- 
ance often coincides with symptoms of pericarditis or 
pleurisy. Their treatment is that appropriate to the 
rheumatism that seems to be their cause, especially iodine 
and the iodides. 

Nodulus Laqueatus is that condition of the hair in 
which it seems to tie itself into knots. The hair is usu- 
ally dry and curly. It is probably caused by handling 
of the hair ; and does not occur spontaneously. 

Noli Me Tangere. See Lupus vulgaris. It has been 
used as a synonym for rodent ulcer. (Crocker.) 

Non-parasitic Sycosis. See Sycosis. 

Norwegian Itch. See Scabies. 

(Edema Cutis, Acute Circumscribed. It is a question 
whether this is a form of urticaria or not. It is certainly 
allied to it in the suddenness of its onset ; in the attend- 
ing ervthema, and digestive or other constitutional dis- 
turbances ; and in the character of its lesions. It differs 
from urticaria in being recurrent in the same locations ; 
in the shading off of the swellings into the surrounding 
skin ; and in being unattended by itching. It is prone 
to occur upon the face, and there often closes up one or 
26 



402 DISEASES OF THE SKIN. 

both eyes in an enormous swelling ; or the lips so that the 
month cannot be opened. In some cases a history may be 
obtained of the occurrence of the same disease in other 
members of the family. It usually begins in early adult 
life and tends to recur. It may occur on the mucous 
membranes, causing suffocative attacks if the larynx is in- 
volved, and acute digestive disturbances if the stomach 
is affected. In the present state of our knowledge it is 
probably well to regard it as urticaria oedematosa. The 
treatment is the same as in urticaria, which see. (See 
Urticaria.) 

(Edema Neonatorum. This disease was formerly con- 
founded with sclerema, but is now separated from it. 

Symptoms. It is a rare disease, that begins upon the 
legs within the first three days of life. The oedema 
spreads upward along the thighs, shows itself upon the 
hands, then upon the genitals and back. It is hard and 
pits only on deep pressure. The skin is of a violaceous 
red, or more or less intense yellow, and feels cold. The 
infant is comatose ; its pulse is feeble ; its breathing 
labored ; and its cry sharp. A high temperature may 
exceptionally be present. Death usually results on ac- 
count of some pulmonary affection, or from collapse. Ex- 
ceptionally, recovery takes place. 

Etiology. The disease occurs in feeble, ill-nourished 
children, in those prematurely delivered, or exposed to 
poor hygienic surroundings. 

Diagnosis. It differs from sclerema in being more 
limited to certain localities, in the skin being more livid 
from the first, and not so hard ; in affecting the dependent 
parts ; and in lacking the stiffness of the joints. (Crocker.) 

Treatment. Though the prognosis is exceedingly 
bad, an attempt should be made to nourish the child as 
well as possible by artificial feeding ; it should be wrapped 
in flannel and kept warm ; and the limbs should be rubbed 
with warm oil, or camphorated alcohol, in such a way that 
the blood is forced toward the heart. 



ONYCHAUXIS AND ONYCHOGRYPHOSIS. 403 

(Eil de Perdrix. A soft corn. 

Oligamie. Anaemia. 

Oligosteatosis. Deficiency of fat secretion. 

Oligotrichia. See Alopecia. 

Onychatrophia. See Atrophia unguium. 

Onychauxis (0 2 n-i 2 k-aV-i 2 s). Onychogryphosis (0 2 n- 
i 2 k-o-gri 2 f-o ; -si 2 s). These are both hypertrophies of the 
nail, either in length, breadth, or thickness ; or in all at 
the same time. When the growth is markedly forward, 
and the nail is much thickened, it is called onychogry- 
phosis. The nail in these instances generally turns to 
one side after reaching a certain length, sometimes so 
much so that a big-toe-nail may lie over the second and 
third toes. If the hypertrophy is lateral, we are apt to 
have onychia, ingrowing toe-nail. The hypertrophied nail 
is rngous, but highly polished, brown, and there is often 
an accumulation of scales under it which at times gives 
rise to a bad odor from decomposition. The toe-nails are 
those most often hypertrophied, but the finger-nails may 
be so affected. 

Etiology. Badly fitting boots and neglect of proper 
care of the nails are causes of onychauxis and onycho- 
gryphosis. They often arise without discoverable cause. 
They may be due to a congenital predisposition. They 
very often occur as part of some chronic skin or constitu- 
tional disease, such as eczema, psoriasis, leprosy, syphilis, 
and ichthyosis. The thickening may be due to disease of 
the matrix or to a thickening of the horny layer only. 

Treatment. The hypertrophied nail may be removed 
by mechanical means such as by the file, saw, or knife. 
The continuous use of salicylic acid sometimes will cause 
the thickened mass to fall off. The oleates of tin and 
lead ; the continuous wearing of rubber cots ; and liquor 
potassa?, are also efficacious in softening the thickened 
mass of the nail. The action of all these agents is as- 
sisted by daily removing the softened layers by meehan- 



404 DISEASES OF THE SKIN. 

ical means. When the hypertrophy is but a part of some 
other disease, it will be benefited by the same means as 
will benefit the cause from which it arises. If it is clue 
to an inflammatory disease of the nail-bed or matrix, that 
must receive attention. (See Onychia and Paronychia.) 
After the nail-deformity has been overcome it may return. 

Onychia (0 2 n-i 2 k'i 2 -a 3 ) or Onychitis (0 2 n-i 2 k-i'ti 2 s). By 
this is meant acute inflammation of the matrix and nail- 
bed. The end of the finger or toe is reddened and swol- 
len, and there is more or less throbbing pain. The nail 
is lifted from its bed, more or less pus escapes from un- 
derneath it, and it is eventually shed. The inflammation 
often spreads to the adjacent parts of the finger, and then 
we have that condition commonly called " whitlow/' 
When the nail falls, a spongy nail-bed is left, often with 
exuberant granulations. Under proper treatment a good 
nail may be reproduced, though in many cases either a 
very much deformed one will result or one that differs 
somewhat in appearance from the other nails. In some 
cases, instead of this phlegmonous form we have a dry in- 
flammation that is known as onychia sicca. Here the 
nail is discolored, its edge thickened and brittle, its sur- 
face rough and more or less pitted. Eventually the nail 
is shed. This condition is met with most often in syph- 
ilis. A chronic onychia is occasionally seen, and is one 
of the causes of onychauxis. 

Etiology. Onychia is due to traumatism or to some 
other disease of the skin, such as syphilis, eczema, psoria- 
sis, parasitic diseases, dermatitis exfoliativa, rheumatism, 
and the strumous state. 

Teeatment. The treatment of onychia varies with 
the stage of the disease and with the cause. Occurring as 
part of some general disease of the skin, the treatment ap- 
propriate to the general disease will be beneficial to the 
onychia. Arising as an independent disease, or resulting 
from traumatism, the application of a 10 to 20 per cent, 
resorcin ointment or plaster will often abort the disease in 



PAGET' S DISEASE OF THE NIPPLE. 405 

an early stage. If the disease lias gone on to suppuration, 
surgical procedures will have to be resorted to, such as 
splitting of the nail or its removal as a whole, and subse- 
quent dressing with iodoform, aristol, or a bichloride so- 
lution. 

Onychomycosis (0 2 n-i 2 k-o-mi-ko , -si 2 s). This term means 
the invasion of the nail by a fungus, such as the tricho- 
phyton or achorion. For further information see tricho- 
phytosis and favus. 

Osmidrosis. See Bromidrosis. 

Osteosis Cutis. A case of osteosis of the skin of the 
foot was reported by Sherwell 1 in 1892. It involved the 
plantar surface of the left foot about the heel and on the 
fourth toe. The patches were of cartilaginous hardness, 
with horny surfaces studded with nodosities. The patches 
were fairly movable over the underlying parts. They 
were painful when stepped on. The patient was a girl six 
years old. The patches were excised, but formed again 
within six months. A histological examination by Cole- 
man 2 showed that they contained cancellous bone. 

Pachydermatocele. See Dermatolysis. 

Pachydermia. See Elephantiasis. 

Paget' s Disease of the Nipple. Synonyms : Mamillaris 
maligna ; Malignant papillary dermatitis ; Epitheliomatose 
eczematoide de la mamelle (Besnier). 

Symptoms. This is a rare disease of the skin that is 
named after Paget, who first described it in 1874. 3 

It usually occurs in women over forty years of age, and 
at first has the appearance of an eczema madidans ; that 
is, it presents "a florid, intensely red, raw surface, very 
finely granular, as if the whole thickness of the epidermis 
had been removed. From such a surface, on the whole or 
greater part of the nipple and areola, there is always a 

1 Journ. Cutan. and Gen.-Urin. Dis., 1892, x., 119. 

2 Ibid., 1894, xii., 185. 

3 St. Bartholomew's Hospital Keports, Vol. x., p. 83. 



406 DISEASES OF THE SKIN. 

copious, clear, yellowish, viscid exudation." Besnier be* 
lieves that its primary stage is a keratosis, which, under 
any irritation, assumes an eczematous appearance. The 
edge of the patch is sharply defined and slightly raised. 
Sometimes, instead of the raw surface, we have crusting, 
or even scaling. Telangiectases may be seen here and 
there. After months or years marked induration is mani- 
fest, pinching up the patch imparting the sensation, as 
described by Mr. Morris, of " a penny felt through a 
cloth." Burning or itching is complained of, which 
makes the disease the more nearly resemble an eczema. 
But it does not yield to the ordinary treatment of eczema, 
and its border gradually extends. The female breast, 
usually the right one, 1 is the most often affected, and 
there it always begins at the nipple, spreading thence over 
the areola and skin. After a few months, or not until 
twenty years, signs of scirrhous cancer appear. The nip- 
ple becomes more and more retracted and ulcerated. 
Shooting pains are complained of. Hard nodules develop 
in the raw surface or deep down in the skin. The mam- 
mary gland itself may become affected. The disease in 
most cases is unilateral. The cancerous cachexia develops 
later with ganglionic enlargements. Crocker and Pick 
have met with it on the scrotum and penis, and one case 
has been reported of involvement of the nipple of a man. 
Pathology. It is still an open question whether the 
disease is malignant from the start, or, beginning as a 
simple inflammation, becomes malignant, just as we find 
epithelioma of the tongue developing upon a leucoplakia. 
Later investigations seem to indicate that the process is 
epitheliomatous from the beginning. J. A. Fordyce's 2 
investigations show the disease to be " an inflammation of 
the papillary region of the derma leading to oedema and 
vacuolation of the constituent cells of the epidermis, 
followed by their complete destruction in some places and 
abnormal proliferation in others." The changes in the 

1 Wickham : Maladie de Paget. Paris, 1890. 



PAGET S DISEASE OF THE NIPPLE. 407 

lactiferous ducts are secondary. Darier and Wiekham 
believe that the disease is due to psorosperras (see 
Psorospermosis). But their theory has not been 
generally accepted as yet, and their so-called psoro- 
spernis are regarded by most authorities as changed epi- 
thelium. 

Diagnosis. Though very important, it is exceedingly 
difficult at first to differentiate positively a case of Paget' s 
disease from an eczema. Eczema of the nipple is very 
common during the childbearing period, while Paget' s 
disease occurs most commonly after the climacteric. In 
eczema we do not have, as a rule, the raw granulating 
surface of Paget' s disease, while we do have more varia- 
tion in the course of the disease, exacerbations and seasons 
of apparent quiescence. In eczema the patch is not so 
sharply defined, and its border is not raised ; about it there 
are apt to be outlying pustules or vesicles, and there is 
not the papyrus-like induration. When the nipple be- 
comes retracted and ulcerations take place, together with 
shooting-pains and enlarged lymphatics, the diagnosis is 
easy. It is said by some that psorosperms can always be 
found in the scabs scraped from the surface of a case of 
Paget's disease. 

Treatment. At the beginning, and while the diag- 
nosis is still doubtful, the usual remedies for eczema 
should be tried. If these fail, as they will if the disease 
is not eczema, or if the right diagnosis is arrived at, 
powerful caustics must be used, if the disease is still 
superficial. We may use, as recommended by Darier, a 
solution of chloride of zinc, one in three, to produce an 
exfoliation of the diseased epidermis, and follow it with 
a mercurial plaster, alternating with iodoform or aristol. 
Or a chloride of zinc paste may be kept on, spread thickly 
on lint, for four to six hours, and the slough poulticed off 
or allowed to separate under wet boric lint, under oiled 
silk, as recommended by Crocker. 

The paste used in the Middlesex Hospital in these cases 
is made as follows : 



408 DISEASES OF THE SKIN. 



R . Zinci chlorid. 

Liq. opii sed. 

Amyli, 

Aquae, 
S. Ft. pasta. 



*iv; 


7 


50 


5 iv ; 


7 


50 


3.i ss ; 
Si; 


3 

30 





M. 



When there is ulceration, but not much induration, the 
surface should be thoroughly curetted and dressed anti- 
septically. When nodules have formed, and there is 
marked induration under an ulcerated surface, the whole 
diseased surface must be freely excised or the breast re- 
moved entire. In fact, it seems to me best to amputate 
the breast as soon as the diagnosis is made, when the pa- 
tient is past the childbearing period. If an operation or 
the use of caustics is unadvisable for any reason, relief to 
the pain and discomfort may be had by dressing with a 
fuchsin solution 1 per cent, strength. 

Panaris Nerveux of Quinquaud belongs to that group 
of obscure diseases in which stand Morvan's disease and 
syringomyelia. It is characterized by swelling of the ex- 
tremities, slight redness, and attacks of intense pain, ter- 
minating in eight to fifteen days by fissure of the finger- 
end and fall of the nail. Sometimes the skin of the 
finger end becomes sclerosed and atrophied. 

Brocq advises in its treatment the constant application 
of chloroform liniment, and of irritant lotions or frictions 
to the cervical region and along the course of the nerves 
supplying the parts. Internally, he advises the valerian- 
ate of ammonia or of quinine. 

Panaritium. See Paronychia. 

Panne Hepatique. See Chloasma. 

Papilloma (Pa 2 p-i 2 l-lo r -ma 3 ). By this term is meant a 
papillary outgrowth from the skin. Such are common 
warts, verrucous eczema, papillary excrescences following 
ulceration, Kaposi's dermatitis papillaris capillitii, ich- 
thyosis hystrix, nsevus unius lateris, and the like. The 
term is, therefore, of uncertain significance. Some au- 
thors have described papillomata apart from the above- 



PARASITIC DISEASES. 409 

designated diseases, and Hardaway reports at length a case 
of general idiopathic papilloma in a seven-months -old 
child. Mental defects have been noted in some of these 
cases. A muco-purulent secretion often is present, well- 
ing up between the papillae. The condition is a rare one. 
Under the name of papilloma area elevatum Beigel has 
described one of these rare cases. 

Papilloma Neuroticum. See Ichthyosis hystrix. 

Parakeratosis. Two forms of parakeratosis have been 
described, namely : Parakeratosis scutalaris l and paraker- 
atosis variegata. 2 

Parakeratosis Scutalaris. This case was that of a man 
forty-one years old. It occurred on the scalp, the whole 
of which, with the exception of a strip at the periphery, 
was covered by a thick, greasy crust that enveloped the 
hair in bundles. Some single hairs had on them cuffs of 
yellowish, white, waxy, horny substance, one inch or more 
long, that were in connection with the crusts on the scalp. 
The growth of the hair was not much interfered with. At 
the edge of the scalp was a hairless, red, dry, and rough 
strip. 

Parakeratosis Variegata. Of this form two cases are 
reported. Both were men. The eruption appeared on 
the thighs, chest, and neck, and later involved nearly the 
whole body, except the head, palms, and soles. The color 
of the eruption was red, forming an irregular network with 
small, sunken patches of normal skin. It was scaly and 
the skin was infiltrated. 

Parasitic Diseases. The diseases of the skin caused by 
well-accepted parasites may be divided into two classes : 
1. Those due to vegetable parasites. 2. Those due to 
animal parasites. 

Group 1 comprises favus, ringworm, chromophytosis, 

1 Internal. Atlas of Rare Skin Diseases, No. 3. 
2 Monatsheftef. prakt. Dermat., 1890, x., 404. 



410 DISEASES OF THE SKIN. 

erythrasma, and pinta. These will be found described 
under their proper headings. 

Group 2 comprises a large variety of parasites. Scabies 
and pediculosis, due respectively to the acarus and pedic- 
ulus, are described at length in this book. Besides these 
we have — 

The leptus autumnalis, harvest-bug, or mower's mite, 
that bores its head into the skin, causes great itching, and 
induces violent scratching and consequent excoriations. 

The demodex fotticulorum is described in relation with 
the comedo. 

The pidex penetrans, chigoe, or jigger, that resembles a 
flea, but penetrates under the skin with its head, sets up 
inflammation and, perhaps, ulceration and gangrene, and 
has to be dug out of the skin with a blunt needle. 

The pulex irritans, or common flea, whose ravages are 
so well known as not to require description. 

The cimex lectularius, or common bedbug, attacks the 
skin for its food, punctures it, and at the same time injects 
an irritating fluid to increase the hyperemia and the food 
supply. A wheal, or raised red spot with a central punc- 
ture, follows the bite, and a purpuric spot results. The 
irritation is relieved by any of the means serviceable in 
urticaria. 

Gnats and mosquitoes and their effects are too familiar 
to all of us to require extended notice. 

Ixodes, or wood-ticks, the filaria sanguinis and filaria 
medinensis, the taenia solium, and the echinococcus all find 
lodgment at times in the human skin. These parasites 
do not exhaust the list, but are the principal ones. 

Parchment Skin. See Atrophia cutis. 

Paronychia (Pa^-o^-Pk'-P-a 3 ). This affection is pop- 
ularly known as a whitlow, run-around, or ingrowing toe- 
nail. Ingrowing toe-nail results from the nail shoving or 
being shoved into the soft parts, either on account of dis- 
ease of the nail itself, or of ill-fitting shoes, or of injury. 
The big-toe-nail, at its inner or outer edge, is the most 



PEDICULOSIS. 411 

common site of the disease, though any toe may be affected, 
and even the finger may suffer. The furrow, fold, and 
bed of the nail all become inflamed, ulcerated, and ex- 
quisitely tender, discharging more or less pus. It is said 
to be more common in young people than in old, and far 
more frequent in men than in women. Paronychia of 
either the ulcerative or non-ulcerative form is frequently 
met with in syphilis. 

Treatment. Severe cases of paronychia most often 
find their way to the surgeon's hands. In syphilitic par- 
onychia general anti-syphilitic treatment is required. In 
the non-ulcerative form mercurial ointment, diluted with 
one or two parts of diachylon ointment, may be used, or 
the mercurial plaster. In the ulcerative form the parts 
should be cauterized with nitric acid or a strong solution 
of acid nitrate of mercury, followed by water-dressings. 
Afterward the part may be dressed with iodoform or 
aristol. Bandaging, strapping with mercurial plaster, 
and the use of rubber cots are also useful methods of 
treatment. 

In ingrowing toe-nail the nail should be filed down the 
middle, or, if that does not relieve the pressure, it may 
have to be removed, in part or entire. The insertion of 
borated lint between the nail and the nail-fold, or using 
boric acid in powder first and some threads of lint or a 
little absorbent cotton to separate the parts, and strapping 
the toe with adhesive plaster, will also answer well. If 
ulceration has taken place, the ulcerated surface should be 
dressed with iodoform or aristol. If the ulceration should 
be covered with exuberant granulations, they should be 
touched with the nitrate of silver stick. As a preventive 
of the trouble, wearing well-fitting shoes and keeping the 
nails clean and cut down the middle are the best means at 
our command. 

Paxton's Disease. See Tinea nodosa. 

Pediculosis (Pe 2 d-i 2 k-irl-o'-si 2 s). Synonyms: Phthiri- 
asis ; Morbus pedicularis ; Pedicularia ; Lousiness. 



412 DISEASES OF THE SKIN. 

Symptoms. There are three varieties of lice that infest 
the human species, namely, the pediculus capitis, pediculus 
vestimentorum, and pediculus pubis. Though they all be- 
long to one family, they differ among themselves, and have 
distinct regions which they invade. 

The pediculus capitis infests the head only, and of that 
the occipital region is the common seat of invasion. 
From there it generally spreads to the parietal region, 
which is one of the best places in which to seek for nits, 
and, maybe, all over the scalp. The lice cause irritation 
of the scalp both by their movements and by the insertion 
of their haustellum into follicles of the skin for feeding 
purposes. The louse has no mandibles. There is no 
such thing as a louse-bite. They simply suck their nutri- 
ment by inserting their haustellum into the follicles of the 
skin. The victim scratches to relieve the itching and ir- 
ritation, and this gives rise to a dermatitis of eczematous 
character with the production of large pustules. A fully 
developed and characteristic case shows the hair in the 
occipital region matted together with a sticky secretion 
and, maybe, blood-crusts, more or less eczematous lesions 
and scattered pustules over the whole scalp, enlarged 
lymphatic glands in the neck, and perhaps a few small 
pustules on the neck and face. When a patient pre- 
sents himself with a pustular eruption on the neck, or 
with a number of large, crusted pustules scattered over 
the scalp, pediculosis capitis should always be suspected, 
and search made for the pediculi or their nits upon the oc- 
cipital and parietal regions. Very often no pediculi can 
be found ; but if the disease is pediculosis, the nits will be 
discovered in the localities mentioned. 

The pediculus vestimentorum, or body-louse, inhabits the 
seams of the clothing, where it lays its eggs, and which it 
leaves only for the purpose of feeding upon the skin. It 
inserts its haustellum into the follicles of the skin, and 
thus produces a small hemorrhagic spot, even with the 
surface of the skin, which is a pathognomonic lesion of 
the disease. This feeding gives rise to itching, and the 



PEDICULOSIS. 413 

victim scratches to relieve it, thus producing a second 
symptom, excoriations. These have one peculiarity, which 
is that they are very apt to take the form of long, paral- 
lel scratch-marks, because the patient digs into his skin 
with all four nails at once. Moreover, as the lice live by 
preference in the shirt-band at the back of the neck, these 
long scratch-marks are most often seen over the shoulders. 
Whenever they are seen we should suspect lice. Excori- 
ations are also seen on the inside of the limbs in locations 
corresponding to the seams of the clothing and about the 
waist corresponding to the location of the waist-band. In 
certain individuals, besides excoriations and hemorrhagic 
specks, we will find ecthymatous pustules, ulcerations, and, 
in very old cases, a great deal of pigmentation, so that 
the skin appears as if affected with a general chloasma. 
Any of these symptoms, hemorrhagic specks, excoriations, 
and itching, which is incessant in pronounced cases, should 
lead us to suspect lice and a careful search of the seams 
of the clothing will reveal them, unless the patient has 
changed everything before coming to us. It must be re- 
membered that the lice dwell both in the linen and woollen 
clothing, and, in bad cases, in the bedding also. 

The pediculus pubis, crab-louse or morpion, has a far 
wider feeding-range than the other varieties. Though its 
favorite feeding-ground is the pubic region, it may be met 
with upon the hair of the abdomen, chest, axillae, beard, 
eyebrows, and eyelashes. Itching, excoriations, and ec- 
zematous lesions are the symptoms it gives rise to, though 
the disturbance is not so great as that caused by the other 
forms of lice. It is the least common variety. It requires 
careful search and a sharp eye to discover the vermin 
at times, as they are almost transparent, and usually are 
attached to the hairs head downward, and close to the 
skin. Cobbold taught that the pediculus that inhabits the 
eyelashes was a distinct species, the pediculus palpebra- 
rum ; but by most authorities the distinction is not made. 
In some cases, instead of red punctate marks, we find dull 
or slaty gray, or, pale blue, lentil- to split-pea-sized mac- 



414 DISEASES OF THE SKIN. 

ules scattered over the pubes, abdomen, extensor surface 
of the arms, axillae, and inside of the thighs. These are 
known as macuke ccerulece, or taches ombrees. They do 
not disappear on pressure. They last for a feAV days, and 
then disappear of themselves. To give rise to these spots 
there must be a predisposition on the part of the skin. 
Most of the few reported cases have been in debilitated 
subjects. According to Duguet, 1 the macules are pro- 
duced by the emptying of the contents of the salivary 
glands of the louse beneath the human epidermis. 

Etiology. These different varieties of pediculosis are 
due to different varieties of lice. The head-louse (Fig. 49) 
is about 2 mm. long and 1 mm. broad, with a triangular 
head and broad thorax and short legs. The body-louse 
(Fig. 50) is larger than the head-louse, being 2 or 3 mm. 
long, with a more oval head and longer legs with more 
developed claws. The pubic louse is broader and flatter 
than either of the others, with rounder head, longer, 
stronger, and more claw-like legs, resembling somewhat a 
crab (Fig. 51). The color of the lice is gray or white. 
They propagate with great rapidity, the young hatching 
out in six or seven days, and being capable within eighteen 
days of propagating their species. It has been calculated 
that two female lice might become the grandmothers of 
10,000 lice in eight weeks' time. The pedi cuius capitis 
deposits its eggs close to the scalp and secretes a glue-like 
substance that sticks the ova to the hair. There may be 
but one ovum on a hair, or many of them. The distance of 
the nit from the scalp shows the length of time that the 
disease has existed. As it takes the hair about a month 
to attain the length of three-fourths of an inch, if we find 
the nit that distance from the scalp we know that it was 
deposited at least one month before. The severity of the 
symptoms to Avhich the lice give rise will vary with the 
individual, some people being far more susceptible than 
others. Infection takes place from other people or from 
infested body or bed clothing. Women and children are 
*Gaz. des Hop., 1880, liii., 362. 



- in 



PEDICULOSIS. 



415 



the most frequent victims of pediculosis capitis ; adults, 
and especially elderly people, of pediculosis vestimento- 



Fig. 49. 




Pedieulus capitis. — Male. 

(After KtJCHENMEISTEE.) 



Fig. 50. 




Pedieulus vestimentorum. 

(After KtJCHENMEISTEE.) 



Fig. 51. 




Pedieulus pubis. (After SCHMAKDA.) 



rum. Pediculosis pubis is most frequently obtained from 
impure sexual intercourse, and is, therefore, most common 
in young adults. Dirt and uncleanness favor all forms, 



416 



DISEASES OF THE SKIN. 



the diagnosis is established 



Fig 



though even the most cleanly may at times harbor ver- 
min. 

Diagnosis. Pediculosis capitis needs to be diagnosti- 
cated from eczema. The characteristic location of its 
lesions upon the occipital region and nape of the neck, 
with its scattered and discrete large pustules over more or 
less of the scalp, should always suggest pediculosis ; then, 
if the lice or their ova are found by searching the hair, 

Nits here, as elsewhere, are 
differentiated from epidermic scales by 
being located upon the side of the hair, 
while the scale has a hair passing through 
its center (Fig. 52). The nit, too, is of 
a yellowish color, somewhat pear-shaped, 
with its larger rounded end upward, and 
it adheres closely to the hair, so as not 
to be readily removed. It is not always 
easy to distinguish pediculosis vesti- 
mentorum from pruritus cutaneus, espe- 
cially if at the time the patient presents 
himself he has clean clothes on through- 
out. Both may occur in elderly people, 
and both may last a long time with no 
other lesion than scratch-marks. In 
pruritus we may find evidences of atro- 
phic skin-changes ; the itching is often 
paroxysmal, and made worse by the 
patient becoming overheated. If we 
find the parallel scratch-marks over the 
shoulders and the hemorrhagic specks, 
we can make a positive diagnosis of 
pediculosis. From urticaria pediculosis 
vestimentorum differs in having hemor- 
rhagic specks and in the parallel scratch- 
marks. Urticaria may complicate a 
pediculosis. Scabies differs from pedic- 
ova of head-iouse at- ulosis in appearing by preference upon 
kaposi.T hair ' (After the anterior face of the wrists, upon the 




PEDICULOSIS. 417 

breasts in women, upon the penis of men, and about the 
umbilicus of both sexes. Its excoriations are not long, 
parallel scratch-marks, but small excoriations. If the 
lice or their ova can be found in any case, the diagnosis of 
pediculosis is made easy. Dermatitis herpetiformis differs 
from pediculosis in wanting the parallel scratch-marks and 
in the markedly grouped character of its lesions. There 
will often be found groups of vesicles scattered about the 
skin. There can be no difficulty in diagnosticating pedic- 
ulosis pubis. Any itching about the pubic region should 
lead to an investigation, which, if carefully made, will 
reveal the pediculi or their nits. 

Treatment. The most ready means of curing the 
disease when in the hairy regions is to shave the hair off 
and make some emollient application to the scalp to cure 
the eczema. But this is not advisable, excepting in chil- 
dren and in men in hospitals, and is not necessary. The 
most speedy and practicable method in public practice is 
to soak the head or pubic region in raw petroleum or 
kerosene, with or without diluting it with sweet oil. This 
may be clone night and morning for two days and the parts 
then washed with soap and Avater. This will effectually 
kill all the lice, and probably destroy the life of the ova. 
The latter must be removed for fear that they are not 
dead, and for this purpose we may use the fine-toothed 
comb to the hair or pull the hair through a cloth saturated 
with vinegar or dilute acetic acid, which will soften the 
gluey attachment of the nits. No attention is to be paid 
to the dermatitis until after the cause of it is removed, 
when it will rapidly get well under any simple treatment. 
In private practice, an infusion or tincture of staphisagria 
(larkspur seeds), or a 10 per cent, solution of carbolic 
acid, or a half to one per cent, solution of bichloride of 
mercury, may be substituted for the petroleum. The 
bichloride should not be used if there is much dermatitis. 
The ointment of the ammoniate of mercury is efficient, 
but, as a rule, an ointment should not be used on hairy 
parts. Blue ointment is a well-known remedy for pedic- 
27 



418 DISEASES OF THE SKIN. 

ulosis pubis, but it is apt to set up a dermatitis that is 
undesirable. 

For pediculosis vestimentorum there is no use in mak- 
ing any application to the skin. The woollen clothes 
should be baked in a hot oven and the underclothing and 
sheets should be well boiled. If this cannot be done, or 
new clothes obtained, powdered sulphur or staphisagria 
may be powdered in all the seams of the clothing, and a 
5 per cent, ointment of carbolic acid applied to the body. 

Pelade. See Alopecia areata. 
Peliosis Rheumatica. See Purpura. 
Pelioma Typhosum. See Maculae cserulese. 

Pellagra (Pe 2 l r -la 3 -gra 3 ). Synonyms : Eisipola lom- 
barda ; Mai de la rosa ; Mai roxo ; Lombardian leprosy. 

Symptoms. But few cases of this disease have been 
reported in this country. Since the number of Italians 
is constantly increasing here it is important for us to be 
able to recognize the disease. It has prodromal symptoms 
of progressive weakness, intestinal catarrh, lassitude, gid- 
diness, headache, and burning sensations in back, limbs, 
hands, and feet. These make their appearance in the 
spring, and shortly after an erythema affects the backs of 
the hands down to the articulation of the first and second 
phalanges, the backs of the wrists and forearms up to the 
elbow, the backs of the feet, if the person goes barefoot, 
the front of the neck and chest to the lower edge of the 
first piece of the sternum, and, in women and children, the 
forehead, nose, and cheeks — that is, all those regions ex- 
posed to the sun. The color is bright, dark, or livid red, 
and is not a simple erythema, as the color cannot be made 
to disappear completely under pressure. The skin is 
often so swollen as to prevent all work. Bullae may form 
upon the affected parts and be followed by erosions. In 
a few weeks desquamation begins, but the skin continues 
discolored and thickened up to July or August, when a 
gradual decline of all the symptoms takes place. During 



PEMPHIGUS. 419 

the winter the patient may appear quite well, but a re- 
lapse is pretty sure to occur during the next spring, and 
to recur each succeeding spring with ever-increasing sever- 
ity of all the symptoms ; the patient emaciates, loses 
strength, develops grave cerebro-spinal neuroses, sinks into 
a typhoid state, and dies. The skin becomes atrophied, 
smooth, shining, cracked, or it may be thickened. There 
is loss of cutaneous sensibility and the erythematous red- 
ness gradually extends over the whole surface of the body. 
The average duration of the disease is five years. 

Etiology. The disease is endemic in northern and 
central Italy, especially in Lombardy, Venetia, and 
JEmilia ; in the southwestern part of France, and in the 
northern part of Spain. It may occur anywhere. Women 
are most subject to it, children least so. It seems to be 
a disease fostered by poverty, want and bad hygiene, and 
to be induced by an almost exclusive diet of decomposed 
or fermented maize, or, possibly, other grains. Some cases 
have been traced to the drinking of spirits made from 
damaged maize. It is, therefore, similar in origin to er- 
gotism. It is not contagious or hereditary. 

Diagnosis. A suspicion of a case being one of pella- 
gra should be aroused whenever an erythema upon the ex- 
posed parts is met with in a person coming from the 
regions in which the disease is known to be endemic, 
especially if it is combined with more or less lassitude and 
hebetude. 

Teeatmext. The treatment of the disease is mainly 
hygienic and symptomatic. Crocker has faith in the effi- 
cacy of arsenic for adults, and frictions with chloride of 
sodium, solution in children. 

Pemphigus (PeW-fi 2 -gu 3 s). Synonyms : Pompholyx ; 
(Ger.) Blasenausschlag ; (Ital.) Pemfigo. 

A chronic disease of the skin characterized by the 
eruption of successive crops of bulla? upon the apparently 
sound skin and with either transient or no antecedent 
erythema. 



420 DISEASES OF THE SKIN. 

At one time every bullous eruption was a pemphigus, 
but with more careful observation and study a number of 
bullous eruptions have been established as distinct dis- 
eases. It is probable that this process of elimination will 
continue. In the meantime a considerable degree of un- 
certainty pervades our knowledge of the disease, both as 
to its symptomatology and etiology, and Ave can only stand 
and await further developments. While in this attitude 
we must have some sort of a chart to guide us, and it has 
been my object to draw its lines with as great sharpness as 
possible. 

The disease is a rare one in this country, only 183 cases 
being reported in a total of 123,746 cases in the statis- 
tical tables of the American Dermatological Association 
from 1878 to 1887. 

Symptoms. It is usual to describe two varieties of 
pemphigus, namely, pemphigus vulgaris and pemphigus 
foliaceus. 

Pemphigus Vulgaris may begin with an outbreak of 
bullae, or there may be more or less constitutional dis- 
turbance before their appearance. The latter condition is 
more often seen in debilitated subjects, children, and old 
people, and consists in chilliness, nausea, and, perhaps, a 
rise of two or three degrees of temperature. These con- 
stitutional disturbances may occur before the appearance 
of each crop of bullae. The characteristic eruption is an 
outbreak of two or more up to a hundred or more pin- 
head-sized vesicles that in a few hours develop into tense, 
oval, hemispherical, prominently raised, fully distended 
bullse with translucent contents. The size of the bullse 
varies ; it may be but one-eighth of an inch in diameter, 
or by the coalescence of several neighboring bullse, large, 
irregular ones of two or three inches in diameter may 
be formed. One distinguishing feature of these bullse is 
that they have no areola, but spring up at once from the 
seemingly healthy skin. Their contents soon become tur- 
bid, or perhaps purulent, and then a slight inflammatory 
halo may form. Rarely hemorrhage into the bullae oc- 



PEMPHIGUS. 421 

curs. The bullae do not tend to rupture spontaneously, 
but to dry up, and leaye the dried coyer as a crust. If 
they are ruptured accidentally, an excoriated place is left 
that heals more or less readily, according to the general 
condition of the patient. Some pigmentation may be left 
for a time to mark the site of the bulla?. 

This eruption may take place anywhere, but affects par- 
ticularly the lower part of the face, the trunk, and limbs. 
It is usually bilateral, and may be roughly symmetrical. 
The life of the individual bulla is two to eight clays ; but 
while one crop is disappearing a new one occurs, and the 
duration of the disease may thus be measured by weeks or 
months. Sometimes there is an interval of weeks or 
months between the outbreaks. In fayorable cases a few 
crops appear, and that is all, the patient making a good 
and complete recoyery. In less favorable cases, or when 
the eruption is very extensive, frequent relapses and many 
excoriations take place, the patient's strength becomes 
exhausted by the constant drain upon his system and loss 
of rest on account of the discomfort of his condition ; he 
may die in a typhoid state, or of some intercurrent affec- 
tion. A number of cases of death from the disease within 
two or three weeks have been reported, and to these the 
name of acute pemjjhigus is given. A few authorities have 
reported acute bullous eruptions running their course in 
three to six weeks as acute pemphigus. Many of these 
cases were probably cases of bullous erythema, as in them 
a preceding erythema is noted in the reports of the cases. 
Most cases run a chronic course, extending over months 
or years. 

In rare instances a diphtheritic membrane may form at 
the site of the bulla, or, instead of healing taking place, a 
gangrenous process may be set up, with considerable de- 
struction of tissue, or hemorrhage may take place in some 
of the bulla?. 

Xeumann has described as pemphigus vegetans a bullous 
eruption in which healing does not take place, but the 
base becomes covered with sprouting granulations and 



422 DISEASES OF TEE SKIN. 

assumes an uneven surface marked by furrows and secret- 
ing a thin fluid. The raw patches thus formed spread 
slowly at their circumference, and neighboring ones coa- 
lesce. The disease proves progressive ; marasmus, and 
finally death closes the scene. Most of the cases are in 
sy phi li tics. 

All the mucous membranes may be affected by pemphi- 
gus, and the excoriations that thus form in the mouth add 
greatly to the discomfort of the patient. The conjunctiva 
is not spared, and if attacked serious deformity results. 

Cases of pemphigus neonatorum have been reported 
from time to time, and epidemics of it have been de- 
scribed. These are so evidently septic in origin that they 
hardly admit of being classified under the heading of 
pemphigus. Careful reading of not a few outbreaks of 
contagious pemphigus reported in the German journals will 
convince one who is acquainted with the bullous form of 
contagious impetigo that a mistake in diagnosis had been 
made by the reporter. Still, until further evidence is 
forthcoming, it is probably advisable to allow that both of 
these varieties of the disease do exist. Pemphigus pruri- 
glnosus is another variety made by writers. It fits in 
quite well under Duhriug's dermatitis herpetiformis. 

Pemphigus Foliaceus differs considerably from pemphi- 
gus vulgaris. It may begin as such or it may develop 
from pemphigus vulgaris. Behrend 1 teaches that the dif- 
ference between the two forms is simply a matter of coher- 
ence between the epidermis and corium, this being so slight 
in pemphigus foliaceus that we have a flaccid bulla instead 
of the tense, fully distended one of pemphigus vulgaris. 

Pemphigus foliaceus is much the more rare variety of 
the disease, Crocker giving its occurrence as one in five 
thousand cases. Its characteristic lesions are flaccid 
bullse, with opaque contents, that soon rupture and leave 
raw, moist surfaces with an edge of ragged epithelium. 
Hie fluid of the bullae changes its position with the posi- 
tion of the patient, always seeking the most dependent 

iVierteljahr. f. Dermat. u. Syph., 1879, vi., 191. 



PEMPHIGUS. 423 

part, and soon becomes purulent. After the disease has 
existed some time the patient emits a sickening odor on 
account of the large amount of the raw surfaces of the 
ruptured bullae that are bathed with sero-pus. Affecting 
at first only a limited space, by degrees the disease spreads 
so that the whole body-surface becomes red and weeping, 
looking like eczema rubrum, with crusts and areas of 
ragged epithelium. The palms and soles are often spared 
on account of the thickness of their epidermal coverings. 
When the skin is thus generally involved it is difficult to 
establish the fact of the occurrence of new bullse. The 
mucous membranes of the mouth and pharynx are affected 
in like manner, becoming converted into raw patches. 
The hair falls out ; the nails become thinner, brittle, 
atrophied, and, maybe, drop off; and ectropion is apt to 
result from contraction of the skin about the eyes. The 
mucous membranes are also attacked, which greatly adds 
to the patient's discomfort. 

The condition of the patient is most deplorable in these 
extensive cases ; his skin is stiff and sore, and perhaps 
smarts ; and after months or years he succumbs to the 
drain on his system, sinks into a typhoid state, and dies. 
During the early part of the disease there may be no con- 
stitutional disturbance. But eventually death is quite 
sure to result, if not from the disease, from some inter- 
current affection against which the patient is unable to 
offer any resistance. 

Etiology. We know very little about the causes of 
pemphigus. The tropho-neurotic theory of the disease 
offers us a cloak for our ignorance, and perhaps is, after 
all, the true one. Experiments have demonstrated that 
bulla? can be made to form by operations on the spinal 
cord, and observation has shown that bullae do form in 
certain spinal diseases. Both sexes are subject to the 
disease. Children are more often affected than adults. 
The septic origin of certain bullous eruptions has already 
been spoken of under the heading of pemphigus neona- 
torum, and a number of cases of acute pemphigus occur- 



424 DISEASES OF THE SKIN. 

ring in butchers and in those engaged in handling meats 
have been reported by G. Pernet and W. Bullock. 1 All 
these ended fatally in a few days. Bullous eruptions are 
hereditary in some families, and in some subjects follow 
slight injuries to the skin. Chilling of the body seems 
to have been the exciting cause of some cases. Some 
have advanced the theory that an excess of ammonia in 
the blood or defective kidney-elimination is the cause of 
the disease. Attacks of the disease have been observed 
to occur with each new pregnancy in some women. 

Pathology. " Most authors regard the actual for- 
mation of the bulla as due to an inflammation of the 
papillary layer, with outpouring of fluid from the vessels ; 
but Auspitz calls it an akantholysis, or loosening of the 
prickle-cell layer, by the sudden escape of fluid from the 
vessels, destroying the young prickle-cells and lifting up 
the epidermis as a whole. Any inflammatory phenomena, 
he thinks, are secondary.' 7 (Crocker.) Micro-organisms 
have been found in the fluid both of the bullae of chronic 
and acute pemphigus, and a peculiar diplococcus has been 
demonstrated by several observers in apparent causal re- 
lation to the disease. 

Diagnosis. If we regard the pathognomonic symptoms 
of pemphigus vulgaris as fully distended bullae springing 
up out of the sound skin without any antecedent erythema 
and without inflammatory halo, and occurring in crops so 
as to run a chronic course, then little difficulty will arise 
in diagnosis. A bullous erythema has bullae arising upon 
an erythematous base or with erythematous lesions else- 
where, and runs a comparatively acute course. Dermatitis 
herpetiformis differs from pemphigus in the grouping and 
multiformity of its lesions, and the great amount of itch- 
ing that attends it. No matter how long it has lasted, it 
is seldom attended by the constitutional disturbances that 
are met with in pemphigus chronicus. In bullous urti- 
caria the bulla rises upon a wheal. The bullous form of 
impetigo contagiosa will be quite sure to present the char- 
1 Brit. Jour. Dermat., 1896, yiii. , 157. 



PEMPHIGUS. 425 

aeteristic impetigo pustules upon the hands or face, and 
search Avill probably discover some child with impetigo 
with whom the patient has come in contact. Varicella 
bullosa occurs epidemically, and runs a short course. 

Pemphigus foliaceus when in its early stage, and affect- 
ing but a small area, is readily diagnosticated by the oc- 
currence of its flabby bulla?, arising without antecedent 
injury. After it has lasted long enough to involve a large 
area it is with difficulty differentiated from eczema ru- 
brum and dermatitis exfoliativa. In fact without the his- 
tory of the case it is sometimes almost impossible to make 
the diagnosis. It may be differentiated from eczema ru- 
b mi id by its crusts being made less of dried exudation than 
of epithelium, by the slighter amount of exudation, by 
the ragged look of some part of the disease, and by care- 
ful watching for and finding the large flaccid bulhe which 
will be sure to appear if the case is one of pemphigus. 
Moreover, a universal eczema rubrum is very rare, and 
the itching is more pronounced. Dermatitis exfoliativa 
differs from pemphigus in the absence of moisture and of 
bulla?, and in the thinness of the exfoliated epidermis. 
Lichen ruber acuminatus is also perfectly dry and presents 
characteristic papules. 

Tbeatmext. The drug upon which most reliance is 
placed in the treatment of this disease is arsenic. "We 
may use Fowler's solution ; or arsenious acid in pill-form, 
as the tablet triturate with piperina, or the Asiatic pill. 
Whatever form is given, it is advisable to begin with 
small doses and gradually increase them until the limit of 
tolerance is reached or the disease is controlled. Unfor- 
tunately it often disappoints us in its effects. Attention 
to diet and hygiene, and the general condition of the pa- 
tient, with the judicious use of tonics, such as quinine, 
iron, and cod-liver oil, will often do as much, if not more, 
than arsenic to cure the patient. 

Locally, dusting powders of oxide of zinc, starch, ly- 
copodium, or bismuth in varying combinations ; lotions of 
lime-water, borax, zinc, liquor plmnbi subacetatis, and 



426 DISEASES OF THE SKIN. 

the like, prove helpful in allaying irritation and discom- 
fort. Lassar's paste is also a good application. Unna 1 
recommends equal parts of linseed oil, lime-water, oxide 
of zinc, and chalk, both to dry up the bullae and prevent 
their return. Linimentum calcis with one minim of creo- 
sote to the ounce is recommended by Hardaway. The 
continuous warm bath has afforded great relief in the 
Vienna hospitals. The bullae may be opened if they are 
troublesome. Alkaline and antiseptic mouthwashes will 
afford relief where the mucous membranes are affected. 

Prognosis. The chances of recovery are uncertain. 
While many cases of pemphigus vulgaris recover, relapses 
are the rule, and if the patient is not strong, or the dis- 
ease has lasted a long time, a guarded prognosis should 
be made. Hemorrhagic, diphtheritic, or fungating bullae 
are of bad augury. Pemphigus vegetans, pemphigus 
foliaceus and pemphigus acutus arising from infection are 
almost invariably fatal. 

Perforating" Ulcer of the Foot is an accident liable to 
occur in those in whom the nerve-supply to the foot is de- 
ficient, as in locomotor ataxia, syphilis, leprosy, and peri- 
pheral neuritis. The most common location for the ulcer 
is at the metatarso-phalangeal articulation of the great or 
little toe, or the cushion of the great toe. It may be only 
on one foot, or both feet may be affected. The process is 
slow, beginning as a proliferation of the epidermis like a 
corn, under which suppuration takes place, and an ulcer 
is left. This goes deeper into the tissues until a sinus 
forms that reaches to the bone. The edges of the ulcer 
are hard. Usually there is little pain, though there may 
be hyperesthesia of the surrounding parts. This pain- 
lessness distinguishes it from a suppurating corn. The 
palms may be affected in the same way as the soles. The 
disease is very intractable, and must be managed on sur- 
gical principles, amputation of the whole or part of the 
foot being required in some cases. Death may result 
from the disease. 

1 Monatshefte f. prakt. Derniat., 1888, vii., 108. 







PERIFOLLICULITIS SUPPVBEES. 427 

Under the name of " Hand and Foot Disease " Hyde 
reports * three cases of ulcerations of the hands and feet 
that lie regards as due to tropho-neurotic disturbances. In 
these cases, with or without functional disturbances, such 
as hyperidrosis and coldness of the hands and feet, bromi- 
drosis, local anaesthesia, vertigo, faintness, and rheumatic 
pains, there were found various grades of dystrophia un- 
guium, from roughness to onychogryphosis, tender and 
painful or insensitive maculations of the hands and feet, 
pigmentary patches on the palms and soles or the back of 
the hands or feet, or both ; different dermatoses, such as 
erythema, eczema, ichthyosis, local alopecias, hypertri- 
chosis, symmetrical tylosis, with or without spontaneous 
exfoliation or recurrence. After a time ulcerations formed 
on the hands or feet, or on both hands and feet. 

Periadenitis Sudoripara. See Abscess of sweat glands. 

Perifolliculitis Suppurees et Conglomeres en Placards. 
Under this lengthy title Leloir 2 has described and figured 
a rare disease of the skin which specially affects the backs 
of the hands. 

Symptoms. It seems to commence as a diffused red 
patch upon which develop small pustules, which itch 
slightly, or as small, red, more or less conglomerate, 
slightly itching elevations that form patches. The patches 
however formed are sharply defined, raised from 2 to 5 
millimeters, round or oval, flattened, and of red, vinous, 
violaceous, or blue color. They vary in size from that of 
a ten-cent piece to a silver dollar, and are often crusted. 
"When the crust is removed the exposed surface is smooth 
or mammillated, but never papillomatous ; and riddled 
with a number of pin-point- to pinhead-size openings, 
corresponding to glandular orifices, many of which are 
closed with a plug of greenish, dried pus. Besides these 
openings there are a number of greenish points that are 
ready to become such whenever the epidermis over them 

iPhila. Med. News, 1887, li., 416. 

2 Ann. de derm, et syph., 1884, v., 437. 



428 DISEASES OF TEE SKIN. 

is removed. At a more advanced stage the openings form 
small pinhead ulcers. By compression of the patch these 
openings give vent either to a drop of pus or serous fluid, 
or little, elongated, vermicelli-like whitish masses. In 
still more advanced cases the patches become more ele- 
vated, fluctuation manifests itself, and a sero-pus may be 
expressed. The patches are usually single, but may be 
multiple. The back of the hand and wrist are the usual 
locations of the disease, but it may occur upon the dorsum 
of the foot or the outer side of the thigh, or be dissemi- 
nated, but chiefly located on the extremities. The course 
of the disease is acute. It is fully developed in eight 
days ; it then continues a Aveek or two and disappears in 
about twelve days more. If badly treated, it may last 
longer, and be followed by a papillary condition. It is 
unattended by subjective symptoms, except slight itching. 
It leaves either no trace of itself, or a delicate superficial 
cicatrix that disappears of itself, or a slight staining that 
soon fades. The hair is unaffected, though the disease 
may involve its follicles. 

Pathology. The disease is a purulent inflammation 
of the skin follicles, specially of the lanugo hairs, and the 
pilosebaceous follicles of regions deficient in true hairs. 
It is possibly microbic in origin. 

Diagnosis. The disease is diagnosticated from tricho- 
phytosis by its more rapid course, and recovery under sim- 
ple treatment ; by the hair being unaffected ; and by the 
absence of the trichophyton in the hair. Anthrax differs 
from it in the more pronounced character of its local and 
general reaction, its central core, and inflammatory indu- 
ration. Tuberculosis verrucosa cutis is much slower in its 
evolution, is serpiginous, and does not yield to simple 
treatment. Eczema differs from it in not having such 
sharply marked borders ; in wanting the characteristic 
openings and livid tint ; and in having more pronounced 
itching, a mucous, sticky discharge, and a comparatively 
long duration. 

Treatment. The treatment is simple and consists in 



PIEDBA. 429 

squeezing out the pus once a day, bathing the part for 
half an hour in warm carbolized water or a solution of 
boric acid, and covering with an antiseptic dressing. If 
papillae have formed, they should be scraped off, and the 
surface touched with nitrate of silver. In some obstinate 
cases it may be necessary to scrape out the whole patch. 

Perionyxis. See Paronychia. 

Perleche (PeV-le 2 sh). According to Brocq, this is a 
disease occurring in infants and affecting the commissures 
of the lips. Their epithelium is pale, macerated, des- 
quamating, while the skin underneath is red and slightly 
inflamed. Sometimes fissures will form that are painful, 
and may bleed when the patient widely opens his mouth. 
The inflammation may spread to the neighboring regions. 
It runs a course of two or three weeks, but is subjected 
to relapse. It is contagious, and is due to a streptococcus. 

It bears a close resemblance to the fissures of the lip 
met with in syphilis, but is marked by an absence of all 
other symptoms of syphilis. 

The treatment consists in touching the diseased parts 
with the sulphate of copper or alum, or an antiseptic 
solution, and in carefully looking after the nursing-bottles. 

Pernio. See Dermatitis calorica. 

Pfundnase. See Eosacea. 

Phagmesis. A rare condition in which it is said that 
feathers instead of hair adorn the body. 

Phtheiriasis. See Pediculosis. 

Pian. See Yaws. 

Pian Ruboide. See Dermatitis papillaris capillitii. 

Piebald Skin. See Leucoderma. 

Piedra (Pe-ad'-ra 3 ). Synonyms : Tinea nodosa ; Tri- 
chomycosis nodosa. 

Symptoms. This disease, or deformity of the hair, is 
said to occur only in Cauca ; one of the United States of 



430 DISEASES OF THE SKIN. 

Colombia, and was first described in 1874 by Dr. N. Oso- 
rio, of the University of Bogota. It consists in the oc- 
currence along the shaft of the hair of from one to ten 
small dark-colored nodes which are very hard and gritty, 
and rattle like stones when the hair is combed or shaken. 
The stony hardness of fhe nodes gave the disease its 
name " Piedra," which is the Spanish for " stone." These 
nodes are always placed at irregular intervals along the 
hair-shaft, beginning at about half an inch from the point 
of exit of the hair, the root being unaffected. " The dis- 
ease occurs most commonly in women, men being rarely 
affected, and it is the head-hair alone which exhibits these 
nodes. The disease is non-contagious, and is met with 
only in warm valleys. 

Etiology. Dr. Osorio thought that the nodes were 
produced by an agglomeration of epithelium in certain parts 
of the hair. Mr. Morris 1 believes it is due to the use of 
a peculiar mucilaginous linseed-like oil, which is used 
particularly by the native women to keep their hair 
smooth and shiny. Another theory is that it is due to 
the use of the water of certain stagnant rivers which is 
very mucilaginous. Heat seems essential for its produc- 
tion, as the employment of either of these fluids will not 
cause the disease in cold climates. 

Microscopical examination of the affected hair shows 
that the nodes consist of a honeycombed mass of pigmented 
spore-like bodies, the whole mass arising from one cell 
which sends out spore-like columns radially in all direc- 
tions. As soon as the cells have reached a certain size, 
they seem to alter their shape, become darker in color, 
and form a pseudo-epidermis. It is, therefore, a fungus 
growth. The nodes were found to be very hard to cut, 
and when considerable force was used they broke. 

Diagnosis. Piedra differs from trichorrhexis nodosa 
in the stony hardness of the nodes, in its occurring princi- 
pally upon the head-hair, in its probable etiology, and in 
the microscopical appearances it presents. 

lancet, 1879, x., 407, 



PITYRIASIS ALBA ATBOPHICAXS. 431 

By the use of hot water the nodes can be entirely 
removed. 

Pigmentary Mole. See Nsevus pigmentosus. 

Pigmentgeschwulst. See Melanotic sarcoma. 

Pigmentkrebs. See Sarcoma. 

Pigmentmal. See Xsevus pigmentosus. 

Pimples. See Acne. 

Pinta (Pent' -a 3 ). Synonyms : Mai de los pintos ; Tinna ; 
Caraate or cute ; Quirica ; Spotted sickness. 

This disease occurs only in southern Mexico, Panama, 
and South America. 

Symptoms. According to Crocker, from whose work 
this account is drawn, it consists of scaly spots varying in 
color, shape, number, and size. They show themselves 
first on the uncovered parts, but may affect any or all of 
the cutaneous surface. The disease spreads by the peri- 
pheral extension of old patches and the formation of new 
ones. The patches are round or irregular in shape, sharply 
or ill defined, and of black, gray, blue, red, or dull-white 
color. The red and white patches are deeper-seated than 
the others, being located in the rete and. corium. The 
patches may be of uniform color or of different tint, but 
do not change their color after they have once formed. 
They are scaly and usually feel rough and dry. The hair 
grows gray and falls. There is some itching, and a bad 
odor emanates from the patient. The course of the dis- 
ease is chronic and shows no tendency to recovery. 

Etiology. The disease is contagious and its spread 
is favored by dirt and neglect. It is most common in 
the poor natives of Indian stock. It is of fungous origin, 
and, in fact, seems to be allied to chromophytosis. 

Treatment. The treatment is the same as for chro- 
mophytosis. 

Pityriasis Alba Atrophicans. This disease begins in 
early life as a partly lamellar, partly branny desquama- 



432 DISEASES OF THE SKIN. 

tion of the skin without redness or any other form of ef- 
florescence. The skin may be aifected wholly or in part. 
After lasting ten to fifteen years it is followed by second- 
ary atrophy of the skin, which becomes thinner, and soft. 
The subcutaneous fat is lost and the veins show through. 

Pityriasis Maculata et Circinata. See Pityriasis rosea. 

Pityriasis Parasitaire. See Chromophytosis. 

Pityriasis Pilaris. See Keratosis pilaris. 

Pityriasis Rosea (Pi 2 t-i 2 -ri 2 -a'-sis). Synonyms : Pity- 
riasis maculata et circinata ; Herpes tonsurans maculosus 
(Hebra) ; Roseola pityriaca (Barduzzi) ; Pityriasis circine 
et margine (Vidal) ; Pityriasis ros6e (Gibert) ; Erytheme 
papuleux desquamatif. 

An acute disease of the skin characterized by an erup- 
tion of rosy-red macules that enlarge into dry, scaly, oval, 
or annular patches with rosy-red peripheries and chamois- 
yellow, wrinkled centers ; it runs a definite course and 
terminates in recovery. 

Symptoms. Though Gibert described pityriasis rosea 
as early as 1868, the disease is but little known in this 
country, not because it does not occur, but because it is 
not recognized. It is one of the rarer skin diseases. 
Most writers tell us that its outbreak is preceded by slight 
constitutional disturbances, such as malaise, loss of ap- 
petite, and headache. These symptoms, in my experi- 
ence, have been as conspicuous by their absence as in the 
case of impetigo contagiosa. The eruption itself most 
often begins upon the upper part of the chest a little above 
the breasts, or, according to Brocq, 1 at the level of the 
waistband, anteriorly and a little to one side, where he lo- 
cates what he calls the " primitive patch." The primary 
lesions are miliary or small papules of pale-red color, sur- 
rounded by an erythematous zone. These soon enlarge into 
rosy-red, slightly raised macules, and slowly increase peri- 
pherally into oval or rounded patches with well-defined bor- 

^nn. de derm, et syph., 1887, viii., 615. 



PITYRIASIS ROSEA. 433 

clers raised somewhat higher than the centers. When the 
patches have attained a diameter of half an inch or more 
the centers begin to clear up by becoming of a yellow, old- 
parchment color, scaly and shiny, while the border is pale- 
red. Later the center may disappear and rings only 
remain, or if two or more patches meet at their borders 
irregular gyrate figures may be formed. All the lesions 
do not attain the same degree of development, and in well- 
developed cases lesions in all stages will be found. The 
lesions are slightly scaly from the commencement, and the 
furfuraceous desquamation continues until the faint mark 
left by the lesion disappears. Itching, usually slight in 
amount and only when the person is warm, is the only 
subjective symptom. Sometimes it is severe. The erup- 
tion is most marked upon the neck, infra- and supra-clavi- 
cular regions, sides of the chest, and shoulders ; it may be 
marked also on the abdomen and buttocks. The whole 
body may be involved, but the hands and feet are usually 
spared, and it is uncommon on the face. After some three 
to six weeks the disease tends to spontaneous recovery, al- 
though it may last for two months. 

Etiology. We know nothing about the cause of the 
disease. It affects all ages and both sexes. Crocker thinks 
that it is most common in children. Most of the cases I 
have seen have been in young adults. This difference may 
be accounted for by the fact that he has a large children's 
dispensary service. Some cases seem to be due to over- 
heating of the skin by wearing too heavy underclothing. 
The disease seems to occur epidemically in some instances, 
and cases are apt to present themselves in groups. Con- 
tagion has not been established. Bazin regards it as ar- 
thritic. It may be parasitic, but as yet the parasite awaits 
demonstration. Yidal l describes a parasite that he names 
the mierosporon anomoeon, as found in pityriasis circine" et 
margine, a disease probably the same as pityriasis rosea. 
Hebra regarded it as a manifestation of trichophytosis, 

^nn. dederm. etsyph., 1882, iii., 22, 
28 



434 DISEASES OF THE SKIN. 

and some authorities still think that some cases are dif- 
fused ringworm. 

Diagnosis. Pityriasis rosea must be differentiated 
from the early circinate, scaling, macular syphiloderm ; 
annular psoriasis ; seborrhoeal eczema ; and disseminated 
trichophytosis. The one most distinguishing feature of 
pityriasis rosea is the wrinkled old-parchment yellow 
of the center of the ring. This is absent from the 
lesions of all the other diseases with which it is likely 
to be confounded. The syphilide is of a less bright-red 
color, and there surely will be some other evidence of 
syphilis to guide us. Psoriasis is far more scaly ; the 
scales are of a white color ; the tips of the elbows and 
the anterior face of the knees will be specially affected ; 
and typical psoriatic patches will be found somewhere. 
Seborrhoeal eczema occurs upon the middle sternal and 
inter-scapular regions particularly ; the patches have a 
greasy feel ; the scales are thicker than in pityriasis rosea ; 
and the lesions show little tendency to spontaneous invo- 
lution. Cases occur in which it is very difficult to make 
the diagnosis. In trichophytosis the fungus is readily 
found under the microscope, which is a decisive test. 
Apart from that, ringworm does not spread so rapidly, 
nor involve such wide areas. 

Treatment. Pityriasis rosea is a self-limited disease, 
and recovery is sure to take place in a short space of time. 
Though treatment seems not to have any marked effect on 
the disease, we may use salicylic acid in vaseline, ten to 
twenty grains to the ounce, or a boric acid or mild sulphur 
ointment, or content ourselves by allaying the itching 
with lotions of carbolic acid (ten grains to the ounce), 
calamine, oxide of zinc, and the like. 

Pityriasis Rubra. See Dermatitis exfoliativa. 

Pityriasis Rubra Pilaris. This disease was first de- 
scribed by the French writers. The following account is 
abstracted from an admirable paper by Besnier. 1 

^nn. de derm, etsyph., 1889, x., 253 et seq. 



PITYRIASIS RUBRA PILARIS. 435 

It has been confused with lichen pilaris, psoriasis, 
lichen ruber and lichen planus, and pityriasis rubra. 
Several cases of lichen ruber reported in this country have 
been declared by the French to be cases of the disease 
under consideration, as well as the lichen psoriasis of 
Hutchinson. Kaposi regards it as the same as lichen 
ruber. It is probable that the two are identical. 

Symptoms. A typical case has three principal ele- 
ments : 1. Asperities of the follicular orifices ; 2. Desqua- 
mation ; 3. Roughness of the skin with exaggeration of 
its folds. The disease generally begins suddenly, without 
prodroma, but there may be some malaise, nervousness, 
insomnia, hyperesthesia of the finger-ends, formication, 
and the like. These prodromata are of short duration, 
and rarely cause the patient to go to bed. The uncovered 
parts are usually first affected with the eruption, but it 
may appear primarily upon the trunk or extremities. The 
initial lesion may be a simple exfoliation ; an erythema ; 
a scaling erythema ; a fine but scanty furfuraceous des- 
quamation ; a shiny redness with pityriasis ; desquamation 
of nail-bed, or fragility of nail. However beginning, the 
more pronounced form appears in a certain number of 
days or weeks, and may develop or abort at any point, or 
be limited to any region, or involve the whole body. 
When fully developed a patch or the whole skin, as the 
case may be, presents the following characteristics : It is 
covered with elevations that are generally conical, but may 
present great diversity of shape. They may be discrete 
or coalesce. They may be so small as to be seen only by 
the aid of a microscope, or elevated many millimeters 
above the surface, with corresponding diameter. They 
are scaly, and vary in color from a silver- white or gray to 
a bright or opaque red, red-brown, or rosy yellow. Their 
summits may be flat, uneven, cone-shape, or truncated, 
giving issue to a hair broken off at a little distance above 
the surface of the skin, and, may be, sheathed by a corneous 
or sebaceo-squamous case. Instead of a hair protruding, 
it may form only a small comedo-like spot at the center 



436 DISEASES OF THE SKIN. 

of the summit, or it may be wanting, or it may seem to 
exist alone, giving to the region the appearance of a badly 
shaven beard. Sometimes the cone presents a crater, at 
the bottom of which is a black point, a punctured scaly 
plate, or a psoriatic point. When several elevations coal- 
esce their borders disappear and form a squamous patch, 
showing the central points and the associated pilary cones. 
The skin is scaly, dry, hard, rough like a file, and presents 
a " goose-skin " appearance. The scales may be scraped 
off without any loss of blood. The disease is generally 
symmetrical, but the lesions may be disseminated without 
order, or in irregular lines, groups, or islands, or may 
unite in tessellated areas. The cone-like elevations do not 
occur on the scalp, and are rare on the soles and palms. 
In these locations the disease takes the form of abundant 
desquamation upon a reddened base. All other regions 
may be affected, the cones forming about the follicles of 
the skin, especially about the hair follicles. The backs 
of the phalanges of the fingers are nearly always affected, 
appearing rough, uneven, and covered with patches of 
characteristic papules. Some variations from the type are 
encountered in different regions, but characteristic types 
will be found somewhere on the body. The hair may fall, 
and the nails may be deformed, opaque, and raised by an 
accumulation of scales under them. 

The general condition is unaltered, and little, if any, 
discomfort is experienced. The duration of the disease 
is indefinite, and relapses are the rule. Second and sub- 
sequent attacks may be shorter than the first. 

Etiology. The etiology of the disease is obscure. It 
occurs at all ages, and in both sexes, but most often in 
infancy or youth, and in males. Many causes have been 
assigned to it, such as cold, excesses, rheumatism ; but 
none of these can be definitely said to be the cause. 

Diagnosis. The disease is to be diagnosed from ichthy- 
osis in not being congenital ; in attacking by preference 
the joints, scalp, face, and neck ; and in its spontaneous 
recovery for a time. From dermatitis exfoliativa by its 



PITYRIASIS RUBRA PILARIS. 



437 



benign course ; its location about the follicular openings ; 
and by the thick scaling of the palms and soles. From 
lichen ruber the diagnosis is difficult, the two being con- 
sidered by many as identical. Hebra (Jr.) has made a 
careful study of the two diseases/ and we give here his 
table of differential diagnosis between them : 



Pityriasis Rubra Pilaris. 

1. Develops in the epidermis. 

2. Efflorescences bear scales from the 

beginning, and often consist of 
accumulations of epidermic scales 
alone which can readily be scratch- 
ed off. 

3. Efflorescences limited to follicle 

mouths, especially those of hair 
follicles. 

4. Extensor surfaces of the extremities 

especially affected. 

5. Microscopically consists of thicken- 

ing of the epidermis, with length- 
ening of the inter-papillary pro- 
jections of the rete mucosum in 
certain places. 

6. Color of efflorescences scarcely differs 

from that of the skin at the be- 
ginning. Afterward becomes rosy 
or brownish-red from consecutive 
hypenemia. 

7. Roughness of the extensor surfaces 

of the extremities, and satin-like 
smoothness on the trunk, with 
fine scales. 

8. Xo accompanying subjective symp- 

toms. 

9. No implication of the general health. 



10. Spontaneous recovery, or chronicity 

without danger to the patient. 

11. Cured by purely local means, though 

often obstinate. 



12. Little or no pigmentation left. 



13. Does not affect the mucous mem- 
branes. 



Lichen Ruber Acuminatum. 

1. Develops in the cutis. 

2. From the beginning they are smooth 

and glistening. Scales form only 
late in the disease. 



3. Are not limited to the follicle mouths. 



4. Flexor surfaces more affected than 

extensor surfaces. 

5. Marked collections of round cells in 

the papillary layers of the corium. 



6. From beginning a bright red, becom- 
ing darker, and may change to 
deep rusty-brown. 



7. Everywhere thickening and rough- 

ness of the skin increasing with 
the age of the disease. 

8. Unbearable itching, great burning, 

restlessness, and jerking move- 
ments of the limbs. 

9. Fever, oedema (especially of lower 

extremities), albuminuria, sleep- 
lessness, general prostration, and 
loss of weight. 

10. Often ends in death, always attended 

with marasmus. 

11. Cured, if at all. by constitutional 

treatment, as with arsenic. Unna's 
ointment of mercury and carbolic 
acid good. 

12. Deep-brown, even blackish-brown, 

pigmentation left which may last 
for months. 

13. Affects mucous membranes, espe- 

cially of mouth and vagina. 



Psoriasis at times bears a strong resemblance to pityria- 
sis rubra pilaris, but it seeks the elbows and knees par- 
ticularly ; its scale is larger : and it is not a follicular 



1 Monatshefte f. prakt. Dermat., 1889, x., 101. 



438 DISEASES OE THE SKIN. 

disease, never presenting comedo-like plugs, broken-off 
hairs, or little elevations. 

Treatment. No satisfactory treatment has been found, 
but the remedies applicable to psoriasis or to ichthyosis 
can be used with advantage. Like in that disease, an at- 
tack may be overcome, but no assurance can be given 
against a relapse. Thus far no fatal case has been 
reported. 

Pityriasis Simplex. This form of scaling of the skin is 
most often seen on the scalp, where it is spoken of as 
pityriasis capitis, and constitutes that form of dandruff in 
which there is a more or less abundant scaling of the 
scalp. The hair is dry and unmanageable, and the head 
itches, especially when the patient sits under a light or 
becomes overheated. The patient is annoyed by the con- 
stant falling of the scales upon his clothing, and if the 
disease is very pronounced brushing of the hair causes a 
small snowstorm of white, light scales. The scalp usually 
looks pale, and will be found covered with fine, grayish 
or yellowish, readily detachable scales. Sometimes, there 
are more or less redness of the scalp and a seam of red- 
ness along the forehead. The eyebrows, bearded portion 
of the face, pubes, and other regions may be affected. 
After an indefinite time alopecia is apt to follow a pity- 
riasis. This disease is usually classed under seborrhoea 
sicca. It is the slightest grade of seborrheal eczema. 
It seems to be inflammatory in its nature. The treat- 
ment is the same as that for seborrheal eczema and for 
seborrhoea. 

Pityriasis Tabescentium is that condition occurring in 
marasmic individuals where we have a scaling of the 
whole skin specially marked on the extensor surfaces of 
the extremities and trunk. 

Pityriasis Versicolor. See Chromophytosis. 

Plaques des Fumeurs. See Leucoplakia. 

Plica Polonica (Pli'-ka 3 Pol-oV-i 2 -ka 3 ). Synonyms : 



POMPIIOLYX. 439 

Trichosis plica ; Trichoma ; (Pol.) Koltun ; (Ger.) Weich- 
selzopf; (Fr.) Plique polonaise ; Polish ringworm. 

Symptoms. This is rather a condition than a disease, 
in which the hair of the head and other parts becomes 
matted together into various shaped masses, on which rest 
all sorts of extraneous matters deposited from the air ; and 
in which are harbored vast hordes of pediculi. Some- 
times these matted tresses are near the scalp, and some- 
times far away, according to circumstances, such as the 
growth of the hair and disease of the scalp. jSTot infre- 
quently an oozing eczema of the scalp will be found. 
The masses will assume all sorts of shapes to which vari- 
ous names have been applied. An offensive odor often 
emanates from the scalp. Occurring among ignorant peo- 
ple, as is usually the case, these plicas are regarded with 
superstition. The patient and friends refuse to have them 
cut off lest some dire disease befall the bearer. 

Etiology. The cause of the condition is want of 
cleanliness combined with an oozing dermatitis of the 
scalp due to pediculi or any other cause. 

Treat mext. The treatment consists in the liberal use 
of soap and water, and curing the dermatitis. If allowed, 
the speediest way of beginning treatment is to cut off the 
hair. The patient must be instructed in the hygiene of 
the scalp. 

Podelcoma. See Fungous foot of India. 

Poils Accidentels. See Hypertrichosis. 

Polytrichia. See Hypertrichosis. 

Polyidrosis. See Hyperidrosis. 

Polypapilloma Tropicum. See Yaws. 

Pompholyx (Po 2 m'-fo 2 l-i 2 x). Synonyms : Dysidrosis ; 
Cheiro-pompholyx. 

This disease was first described by Tilbury Fox and 
Jonathan Hutchinson from the same case, though inde- 
pendently of each other. The former thought that it 



440 DISEASES OF THE SKIN. 

was due to distention of the sweat glands, and named it 
dysidrosis, while the latter named it cheiro-pompholyx 
from the bullous character of the eruption and its occur- 
rence upon the hands. As it occurs upon the feet as Avell 
as the hands, Hutchinson's name is a misnomer. 

Symptoms. The first thing that the patient notices is 
a burning and itching of the palms, or soles, and sides of 
the fingers or toes. In a few hours small, clear, sago- 
grain-like vesicles, sometimes grouped, and with an ery- 
thematous zone about them, appear in these locations. 
They are often very numerous, and some of them run 
together to form small and large bullae. Their contents 
are at first neutral ; later they become turbid and have 
an alkaline reaction. These vesicles do not tend to spon- 
taneous rupture. In a few days they dry up, their covers 
fall, and large and small, dry, red surfaces are left to mark 
their locations. If the lesions have been very numerous, 
the whole of the old skin may be shed. In slight cases 
the palms or soles will be dotted over with irregularly 
shaped red spots with ragged edges. As a rule, the backs 
of the hands and feet are unaffected, though the rule has 
many exceptions. The patients are seldom in perfect 
health, and are usually nervously depressed. Hyperi- 
drosis of the affected parts commonly accompanies or 
precedes the outbreak, and sometimes a lichen tropicus 
will be found on the trunk. The duration of the attack 
varies from a few days to three or four weeks, and re- 
lapses in the same or following years are common. Most 
all cases are seen in the summer. It is usually symmet- 
rical, though one side may be affected before the other. 

Etiology. Over the causes of the disease there has 
been and still is active discussion. It seems to be in some 
way connected with the sweat glands, but whether it is a 
simple impediment to the escape of the sweat or an in- 
flammatory disease is not determined. Some able pathol- 
ogists ally the disease to herpes. The occurrence of the 
disease in hot weather points to the sweat apparatus as 
the organ at fault. There is probably a vasomotor neu- 



POMPHOLYX. 441 

rosis at the bottom of the trouble. It affects all ages and 
both sexes, though most common in young adult women, 
and in those who are of nervous temperament, or the sub- 
jects of worry and over-fatigue. 

Pathology. Robinson, who has carefully studied 
this disease, regards it as a neurosis allied to herpes and 
pemphigus. He thinks that it has nothing to do with the 
sweat glands, but that it is inflammatory. The contents 
of the vesicles, he shows, is not sweat, but serum, aud 
the reaction of the fluid is alkaline or neutral in its early 
stages, never acid. It also contains a large amount of 
albumin and some fibrine. It comes from the papillary 
blood vessels, and passing between the rete-cells collects 
in different situations in the stratum mucosum. 

Diagnosis. Pompholyx must be differentiated from 
eczema, scabies, pemphigus, and erythema bullosum. It 
differs from eczema in its vesicles not tending to break 
down of themselves ; in not presenting a moist surface 
after the vesicle-tops fall ; and in running a more definite 
course. The sago-grain-like appearance of the vesicles is 
not peculiar to it, as it is frequently seen in eczema of the 
hands, and is due to the thickness of the epithelium pre- 
venting the ready escape of the fluid. Scabies may bear 
a close resemblance to pompholyx, but can be readily dif- 
ferentiated by finding the burrows, and by the presence 
of the eruption at the same time upon the anterior face 
of the wrists, the breasts in women, the genitals in males, 
and about the umbilicus in both sexes. Pemphigus of the 
hands and feet is exceedingly rare in adults, and pom- 
pholyx has never been reported in infants. Moreover, 
pemphigus lacks the vesicular lesions of the sides of the 
fingers. Erythema bullosum is always on the backs of the 
hands, and is not itchy, though it may burn. 

Treatment. A simple astringent ointment, as of 
oxide of zinc, or diachylon ; or one of the oleate of zinc 
or lead ; or an alkaline lotion, will allay the irritation 
and hasten the disappearance of the disease. General 
hygiene should be enforced ; and tonics of iron, arsenic, 



442 DISEASES OF THE SKIN. 

or whatever seems indicated by the condition of the pa- 
tient, given. 

Porcellanfriessel. See Urticaria. 

Porcupine Disease. See Ichthyosis. 

Porrigo Contagiosa. See Impetigo contagiosa. 

Porrigo Decalvans. See Alopecia areata. 

Porrigo Favosa. See Favus. 

Porrigo Furfurans. See Trichophytosis capitis. 

Porrigo Granule. See Pediculosis. 

Porrigo Larvalis. See Impetigo. 

Porrigo Lupinosa. See Favus. 

Porokeratosis (Por-o-ke 2 r-a 2 t-o'-si 2 s). Under this name 
Mibelli, 1 and later Respighi, 2 have reported a disease of 
the skin that occurs in the form of raised or sunken 
patches of various sizes and irregular shape, with a con- 
tinuous thin, horny, linearform ridge about them. The 
disease occurs on the dorsal surface of the hands and feet, 
the extensor surface of the forearm and leg, and exception- 
ally on their flexor surface. It may also occur on the 
face, neck, and scalp, and the mucous membrane of the 
mouth. There are no subjective symptoms. Some of the 
lesions may disappear spontaneously. Generally the dis- 
ease spreads slowly so as to occupy large areas. 

Respighi describes five distinct forms : 1. Miliary and 
submiliary papules ; 2. Hempseed- to lentil-size papules ; 
3. Guttate to. nummular papules ; 4. Ring and circinate 
disks, which is the most common form. Their edges are 
raised, regular, toothed, or zig-zag, and may be composed 
of papules arranged in chains. The disks may be round, 
oval, or elliptic ; 5. Ball or muscle-shaped lesions, 3 to 4 
mm. high. All forms begin as papules. The disease is 
bilateral and tends to symmetry. The nails may be 
affected, becoming cloudy, striped longitudinally, rough, 

1 Monatshefte f. prakt. Dercnat., 1893, xvii., 417. 
2 Ibid., 1894, xviii., 70. 



PRAIRIE ITCH. 443 

thickened, raised from their bed, brittle, and perhaps they 
may be shed. 

The disease usually begins in early life but may begin 
at any age. It is hereditary in some families. Most of 
the cases are in men. Many members of the same family 

Fru. 53. 




Porokeratosis. (RESriGHi.) 

may be affected. It consists in a hyperkeratosis of the 
sweat gland orifices, and destroys both the glands and 
hair follicles. It is thought by Mibelli to be a species of 
nsevus unius lateris. 

Port-wine Mark. Sec Nsevus. 

Post-mortem Warts. See Tuberculosis verrucosa cutis. 

Prairie Itch. This disease has been found to be in most 



444 DISEASES OF THE SRW. 

cases a combination of pruritus hiemalis and scabies. It 
is not a disease sui generis. 

Prickly Heat. See Miliaria. 

Prurigo (Pru-ri'-go). Synonyms : Strophulus prurigi- 
neux ; Scrofulide boutonneuse benigne ; (Ger.) Juckblat- 
tern. 

A chronic disease of the skin characterized by begin- 
ning in infancy as an urticaria, and changing into a 
recurring eruption of pale, hard, exceedingly itchy, dis- 
crete papules, especially upon the extensor surfaces of the 
extremities. It increases in severity from above down- 
ward, and is accompanied by enlargement of the inguinal 
glands. 

There are two types of this disease, namely : prurigo 
mitis and prurigo ferox. These two blend into each other. 
While the malady is more commonly reported from Vienna 
than elsewhere, it occurs in many countries. It is rare in 
this country. The name is used by most French writers 
as synonymous with pruritus, and English writers quite 
commonly speak of " pruriginous " diseases when confu- 
sion would be avoided by using the adjective " pruritic." 

Symptoms. The disease begins in infancy, quite com- 
monly toward the end of the first year, as an outbreak of 
urticarial wheals of various sizes and shapes. The urtica- 
rial eruption persists, but after a time a preponderance of 
small wheals will be remarked, and a preference for the 
trunk and the extensor surfaces of the limbs. During the 
second or third year the urticarial element is lost and the 
characteristic papular eruption gradually preponderates, 
and at last takes its place. The papules are pinhead to 
hemp-seed in size, flat, firm, of the color of the skin, or 
of a bright-red, rosy, or yellowish-white color, and in many 
cases so little raised as to be felt rather than seen. When 
the skin is irritated the papules may assume the character 
of small wheals. The efflorescences are located principally 
upon the extensor surfaces of the limbs, and more sparsely 
on the trunk, w r hile the scalp, the flexures of the large 



Ui 



PRURIGO. 445 

joints, the palms, soles, and genitals are free. The papules 
are not grouped. 

Pruritus is intense, so that excoriations and torn papules 
are present over all the affected parts. The patients have 
a pale, weary expression of countenance, and evidently 
are in poor condition. The skin is often dry and it may 
be scaly. 

When the lesions are but few in number and scattered 
about upon the extremities, we have prurigo mitis. When 
a great number of papules are present, and the disease is 
widespread, we have prurigo ferox. Now we have the 
typical form of the disease such as is shown in the Vienna 
skin clinics. We note that the skin feels rough ; that it 
is strewn over with a great number of small papules which 
are of the color of the skin or pale-red ; defaced with 
scratch-marks ; eczematous in places ; darkly pigmented, 
it may be brown, from constant irritation of the scratch- 
ing, and that the color of the general integument is in 
strong contrast with the pale color of the face ; that the 
skin is thickened in some places while the flexures of the 
joints are free from change and as soft as normal ; that 
these changes in the skin are progressively worse from 
above downward, so that the legs from the knees down 
are most markedly involved ; and that the inguinal glands 
are enlarged so as to form buboes. Ecthymatous lesions 
may arise. The intensity of the itching may be so great 
as to prevent sleep, and even in some cases to drive the 
patient insane. 

The duration of the disease is indefinite ; it may last a 
lifetime, but often tends to disappear with advancing 
years. The type of the disease remains the same through- 
out — that is, prurigo mitis does not change to prurigo 
ferox. 

Etiology. Prurigo affects both sexes, though it is 
more prevalent in the male sex. It is far more common 
among the poor and those who are uncleanly. It is not 
uncommon to find several members of the same family 
with the disease. A phthisical family history has been 



446 DISEASES OF THE SKIN. 

affirmed to be an etiological factor by some authorities. 
Some cases are better in winter and some in summer. 
It is a disease of infancy continuing through life. A 
neurosis probably is the underlying cause of the phenom- 
ena, and it seems to be related to urticaria. Histolog- 
ical studies have not yet put the disease upon a sure ana- 
tomical basis. 

Diagnosis. The diagnosis is made by the occurrence 
of pale papules upon the extensor aspects of the limbs ; 
by the increasing severity of the symptoms from above 
downward ; by the enlargement of the inguinal glands, 
by the peculiar look and complexion of the patient, and 
by the continuance of the disease from early infancy. It 
is differentiated from eczema by the sparing of the flexures 
of the joints ; by the presence of its characteristic pap- 
ules, and by its greater obstinacy. From papular urtica- 
ria it can be distinguished only by its general course. In 
fact, a doubtful case must be carefully studied over a con- 
siderable length of time before a positive diagnosis can be 
made. Scabies and pediculosis can be readily separated 
by the occurrence of the lesions on the palms, between 
the fingers, and on the genitals in the one ; and the paral- 
lel scratch-marks over the shoulders in the other. Ich- 
thyosis spares the flexures as does prurigo, but it is marked 
by polygonal scales, not papules ; and is free from the 
great number of excoriations found in prurigo ; it is, 
moreover, a disease that affects the whole body-surface 
more generally. 

Treatment. The disease is exceedingly obstinate to 
treatment. The patient must be put in as good a physi- 
cal condition as possible by means of hygiene, cod-liver 
oil, iron, and a good diet. Tincture of cannabis indica is 
commended by Crocker for relief of the itching in doses 
of ten minims increased to thirty minims to a ten-year- 
old child given three times a day directly after meals, and 
intermitted for two weeks after every six weeks. Simon * 
and others recommend pilocarpine hypodermically, fifteen 



PRURITUS CUTANEUS. 447 

niininis of a 2 per cent, solution once a day, for adults, 
or a corresponding quantity of jaborandi by the mouth. 
After the dose the patient is to be put in bed and covered 
with woollen blankets, where he is allowed to sweat for 
two or three hours. Carbolic acid, fifteen to twenty 
grains a day in pill, and the bromide of potassium have 
their advocates. Antipyrine and phenacetine exert a con- 
trolling influence over pruritus, and they are among the 
most valuable internal remedies in prurigo. The latter, 
though not so active as the former, should be tried first in 
full doses, as it is much safer. 

External treatment is very important. Naphthol is 
most highly commended, a 2 to 5 per cent, solution, ac- 
cording to age, being rubbed in every night, and a bath 
of naphthol-sulphur soap being taken every second night. 
In older children and adults the soap treatment of Hebra, 
as described in the section on Eczema, is useful. Sulphur 
ointment used as in scabies after a daily bath ; tar used 
as in psoriasis ; a 5 or 10 per cent, lotion of carbolic or 
salicylic acid, or the same combined with vaseline ; a 5 
per cent, boric acid ointment, all have their advocates, 
and all may be tried in obstinate cases. Baths followed 
by inunctions of cod-liver oil, simple oil, tar oil, or lard, 
are often useful ; as well as baths of alum, soda, and cor- 
rosive sublimate. Jacquet and Tenneson report great 
amelioration from wrapping the affected parts in some 
protective dressing, such as rubber sheeting or absorbent 
cotton. The spinal douche might do good in some cases. 
Treatment should be continued for weeks or months after 
apparent cure of the disease. 

The prognosis as to cure is bad, excepting in recent and 
not severe cases. These may be cured, but, as a rule, all 
we can do is to mitigate the patient's discomfort. Relapses 
are the rule. 

Pruritus Cutaneus (Pru-ri'-tu 3 s). Itching of the skin 
is a symptom common to a great variety of dermatoses. 
Indeed, it has been said that skin diseases might be classi- 



448 DISEASES OF THE SKIN. 

fied under two divisions : those that itch and those that 
don't itch. Eczema, scabies, urticaria, prurigo, pedicu- 
losis, are all eminently pruritic, but do not concern us 
here. 

Symptoms. By pruritus cutaneus we mean a func- 
tional neurosis of the skin whose only essential symptom 
is itching. This induces scratching, and scratch-marks 
are always to be found as a secondary symptom. These 
usually are in the form of scratched papules. If the 
itching is great and continuous, we will have other sec- 
ondary effects, such as thickening and pigmentation of the 
skin, and eczema of various degrees. 

The itching varies greatly in degree from simply an 
occasional slight attack to such an intense degree as to 
render the patient's life unendurable and tempt to suicide. 
The pruritus is commonly paroxysmal, but in some cases 
the pauses between the paroxysms are so short that the 
itching is practically continuous. It is almost always 
worse at night. Changes of temperature aggravate the 
itching, as a rule. Very commonly warmth makes mat- 
ters worse, and the sufferer will begin to scratch and keep 
on scratching while in the neighborhood of a fire, or in 
bed warmly covered. He cannot resist the impulse to 
scratch, and so in bad cases he shuns society and becomes 
morbid. 

Under the general title of pruritus are often placed 
various paresthesia?, such as formication, tingling, and 
burning. 

The pruritus may be general or local. Thus we have 
pruritus universalis, a term that is rarely to be applied 
with strict accuracy, as it is seldom universal, and only 
general. In these cases the itching is now in one place and 
now in another. Bulkley, 1 by a series of observations on 
himself, strove to establish some law of reflex excitation, 
in which he was so far successful as to find that if he 
scratched one spot that itched, he relieved the sensation 
there, only to have it break out elsewhere. This general 

iJourn. Cutan. and Gen. -Urin. Dis., 1887, v., 459. 



FBUMTUS CUTANEUS. 449 

pruritus is most often encountered in pruritus senilis, or 
the itching of the skin of old people, and in pruritus hie- 
malis and pruritus aestivalis which are induced respectively 
by the cold of winter or the heat of summer. These very 
often manifest themselves on the thighs and legs only. 

Of local pruritus we have many instances. Thus we 
have pruritus ani which afflicts both sexes and in which 
the itching: extends to the mucous membrane of the anus. 
This same extension is also seen in pruritus vulvae. This 
localized itching, with the corresponding pruritus scroti in 
men, often occurs in connection with pruritus ani. In all 
these three the parts almost always become thickened and 
eczematous from the constant rubbing and scratching to 
which they are subjected, and nymphomania is sometimes 
a consequence of the itching vulva. The scalp, face, 
especially about the nose and mouth ; the palms and 
soles, and between the fingers and toes, are frequent sites 
of itching. More rarely local areas anywhere will be 
affected with recurring attacks of itching. 

Etiology. That the pruritus is due to a functional 
disturbance of the sensory nerves there is no doubt. For 
success in treatment and accuracy in prognosis it is neces- 
sary for us to endeavor to determine the cause of such 
disturbance. Hepatic derangements cause a certain pro- 
portion of cases. The intense itching of the skin in jaundice 
is evidence of this. Digestive disorders and constipation ; 
excretory disorders, as of the kidneys and skin ; albumi- 
nuria ; lithsemia ; and diabetes, all have influence in 
causing pruritus. Depressed mental states, and the dis- 
orders of the nervous system induced by the abuse of 
tobacco, tea, alcohol, opium, and the like, produce pruritus. 
Reflex influences from the sexual sphere, and the power 
of imagination, are responsible for some cases. In illus- 
tration of the latter everyone knows how many people will 
begin to scratch when the subject of lice is mentioned ; 
and how that long after the acarus is killed in scabies the 
patient will continue to complain of itching, and will not 
be assured that he is cured of his disease, 
29 



450 DISEASES OF THE SKIN. 

In pruritus senilis the skin will be found to be atrophied 
and the fatty tissue underlying it absorbed, in not a few 
cases. Pruritus ani is often due to haemorrhoids or fis- 
sures of the mucous membrane ; or to ascarides ; or to 
the excessive use of tobacco. Stricture of the urethra has 
been found to be the cause of both it and pruritus scroti. 
Pruritus vulvae is very often due to pregnancy or tumors 
of the uterus or ovaries. In this form diabetes is quite 
commonly the cause. Pruritus hiemalis begins at any 
time from October to January, and continues until the 
spring is well advanced. The effect of cold upon the 
skin seems to check the secretory functions. 

Bulkley has found pruritus to be more common in men 
than in women, fifty of his eighty cases being men. In 
some families an itching skin seems to be hereditary. 

Diagnosis. If we bear in mind that pruritus has no 
lesion of its own ; and if, whenever a patient complains 
of itching of the skin, we institute a search for the pedic- 
ulus, or the itch-mite, or their lesions ; or the wheal, or 
at least a history of it ; and find none, then we have gone 
far toward establishing a diagnosis of pruritus. Some- 
times it is difficult to determine whether an eczema is sec- 
ondary to the scratching for the relief of itching, or the 
itching is a part of the eczema. Only an attempt at cur- 
ing the eczema and long observation of the case will en- 
able us to make a true diagnosis. Many errors of diag- 
nosis will be changed by close study, as true pruritus is 
not so common as other itching diseases. Bulkley found 
but eighty cases in 5,000 private cases. 

Treatment. To find and remove the cause is the first 
essential in treating a case. How difficult this task may 
be will be seen by a study of its etiology. Nevertheless 
the patient must be considered, and every organ interro- 
gated, and any deranged function regulated as far as pos- 
sible. Tea, coffee, and tobacco should be interdicted ; a 
dietary carefully laid down ; and the rules of hygiene, 
such as those relating to exercise, bathing, and clothing, 
enforced. To relieve the itching as such, we may give 



PRURITUS CUTANEUS. 451 

the tincture of cannabis indica, 10 minims three times a 
day, in water after meals, and gradually increase the dose 
up to 20 or 30 minims ; or the tincture of gelsemium in 
10-minim doses every half-hour till one drachm is taken 
or toxic effects produced ; hypodermatic injections of pilo- 
carpine, yL- to J- of a grain; quinine, 10 to 15 grains at 
bedtime ; carbolic acid, 1 to 2 minims three times a day ; 
wine of antimony, 5 to 7 drops after meals ; salicylate of 
soda, 15 grains, or antipyrin or phenacetine in full doses. 
Besnier recommends valerian, or valerianate of ammonia. 
But the relief so obtained is transitory, and we should not 
rest content until we have found out, and where possible 
removed, the internal underlying cause. Opium should 
never be given, as it causes pruritus. 

The external treatment is of great service in alleviating 
the itching, even if it does not cure the disease. For this 
purpose general baths with soda (3viij-x to 30 gallons), or 
nitric or hydrochloric acid (oj to 30 gallons), may be used. 
After the bath the body is to be dried by wrapping in a 
warmed sheet and patting the skin dry ; then the skin 
should be smeared with vaseline and powdered with corn- 
starch from a flour-dredger. For local pruritus we may 
use lotions, of which one of the most efficient is carbolic 
acid. 

R. Acid, carbol., 3j _ ij- 

Liq. potassse, 5J- 

01. lini., gj. 

Sig. Shake before using (Bronson). M. 

The patient should be cautioned to tap the skin gently 
with this, and not rub it in. So used it will cause no 
damage and will stop the itching for hours. It may be 
used as a spray in the strength of half an ounce to the 
pint of water with one ounce of glycerin. To this 5 to 
20 minims of oil of peppermint maybe added (Hardaway). 
Alkaline lotions, as bicarbonate of soda, 5j to the basinful 
of water ; or acid lotions, such as vinegar dabbed on the 
itching spot, will often relieve. Liquor carbonis deter- 



452 DISEASES OF THE SKIN. 

gens, 5j to Siv ; thymol, 5ij ; liquor potassii, 5j ; glycerin, 
3iij ; aquae, Sviij (Crocker). Liquor picis alkalinus, 3j 
to Siv ; perchloride of mercury, gr. J-3 to Sj of water. 
All these are well attested as useful. Peroxide of hydro- 
gen is highly commended by Bronson. It may be used 
as a toilet wash two or three times a day. 

For pruritus ani, scroti, et vulvae, sitting over a basin 
or pail of very hot water and sopping it up on the parts, 
followed by patting the skin dry and using a starch 
powder will often give the patient a quiet night. If an 
eczema is present, that must first be cured. Cocaine lo- 
tions, as one of 20 per cent, of cocaine and 5 per cent, of 
glycerin ; or menthol 3 to 10 per cent, in oil of sweet 
almonds, or of glycerin and water ; carbolic acid lotions 
are also useful, as well as many mercurial ointments. 
Cocaine had best be left alone, as there is always danger 
of forming the cocaine-habit from the use of this seductive 
drug. Bulkley's antipruritic powder, of one drachm each 
of camphor and chloral, rubbed together till liquefied, and 
added to one ounce of starch powder, will sometimes prove 
very effective. Painting the parts Avith nitrate of silver, 
16 grains in spts. aetheris nitrosi Sj, is another good pro- 
ceeding. A saturated solution of boric acid is also good. 
When the parts are excoriated neither menthol, pepper- 
mint, nor the chloral-camphor powder can be used. 
Guiacol, 5 or 10 per cent, with starch powder is One of 
the newer remedies. Suppositories containing belladonna, 
cocaine, or creasote may give relief in these cases. Of 
course haemorrhoids, fissures, or other rectal diseases must 
be cured if found. 

In pruritus hiemalis it is sometimes necessary for the 
patient to wear linen underclothing next to the skin ; and 
over these the woollens usually worn. Other patients 
find more relief from wearing silk underclothing. The 
treatment indicated above for pruritus is applicable here 
also. 

In some obstinate cases of general pruritus great ame- 
lioration may be obtained by the actual or Paquelin cau- 



PSORIASIS. 453 

tery applied lightly along the spine. The same means 
has sometimes been successful in localized pruritus, as of 
the vulva or scrotum, but now the parts themselves are 
touched with the cautery. Spinal douches are highly 
thought of by some French authorities. 

Prognosis. The prognosis is doubtful. Some cases 
are very obstinate, and some are incurable. Happily, 
thorough study of the case will be rewarded in most 
cases by a cure. 

Pruritus Hiemalis. See Pruritus cutaneus. 

Pseudo Exantheme Erythemato-desquamatif. See Pity- 
riasis rosea. 

Pseudo Erysipelas. By this term is meant cellulitis or 
diffused phlegmon. 

Pseudo Leucaemia Cutis is a very rare disease. A case 
is reported by Joseph * as occurring in a man of previous 
good health. It commenced as a number of small glan- 
dular swellings in the neck. Shortly after their appear- 
ance severe general pruritus began to affect the patient. 
Then the inguinal and axillary glands became greatly en- 
larged, and a general eruption of hempseed-sized papules 
occurred. These were more easily felt than seen, and 
were of a pale-red color. The epidermis over them was 
unchanged. Wheals also appeared that changed into pap- 
ules. The skin between the papules was dark-colored, 
thickened, and dry. The case ran a chronic course, 
marked by relapses. 

Pseudo Lupus. See Dermatitis, blastomycetic. 

Psora. See Psoriasis. 

Psoriasis (So-ri 2 -a r -si 2 s). Synonyms : Lepra ; Lepra 
alphos ; Alphos ; Psora ; (Ger.) Schuppenflechte. 

A disease of the skin characterized by an eruption of 
round or oval, bright-red patches covered with more or 
less thick, silvery-white, adherent scales ; by occurring 

1 Deutsche med. Wochenschrift, 1889, p. 946. 



454 



DISEASES OF THE SKIN. 



especially upon the extensor surfaces of the elbows, knees, 
and extremities, and upon the scalp ; by running a chronic 
course marked by remissions and relapses ; and by being 
more or less pruritic. 

This is one of the more common skin diseases, forming 
in this country about 3 per cent, of all cases. 

Fig. 54. 




*»: 





Psoriasis. (From Prof. G. H. Fox's service at the Yauderbilt clinic.) 



Symptoms. Its features of variously sized, sharply de- 
fined red papules or patches covered with more or less 
abundant silvery-white scales that occur specially upon 
the extensor surfaces of the elbows and knees, are so pro- 



PSORIASIS. 455 

nounced that the disease once seen is readily recognized 
even by the tyro. 

The primary lesion of psoriasis is always a rather 
bright-red, pinhead-sized papule covered with a dry sil- 
ver y-vvlii te or grayish scale. It is rare to meet with a 

Fig. 55. 




r 



Psoriasis. (From Piof. G. H. Fox's service at the Vanderbilt clinic.) 

case in which these small lesions are seen alone, and when 
it is, it is called psoriasis punctata. Careful search of any 
but an inveterate case will be rewarded by finding these 
lesions somewhere on the body. They soon begin to en- 
large by peripheral extension into larger patches which 



456 DISEASES OF THE SKIN. 

have received various names, although all the same dis- 
ease. When they attain the diameter of about one-quarter 
of an inch, and bear a rather thick scale, they look like 
drops of mortar, and the case is then spoken of as pso- 
riasis guttata. When the lesions form coin-sized patches 
we speak of psoriasis nummularis. A single patch may 
grow to be two inches in diameter, or even larger, and 
preserve its circular shape. But the large patches are 
usually formed by the coalescence of several smaller 
patches, and may attain to a size sufficient to cover the 
greater part of a limb, or even the trunk. Its circular 
outline is now lost, and the patch has a more or less scal- 
loped, indented border bearing so strong a resemblance to 
the maps drawn by children, that Piffard suggested the 
term psoriasis geographica for it ; but the more usual name 
is psoriasis diffusa. After a patch has reached a certain 
size it may clear up in the center and form a ring, and in 
this way we have psoriasis circinata. Several of these 
rings may meet at their circumference, when the points of 
contact will disappear and gyrate figures will be formed. 
When the eruption is so general as to involve the whole 
or the greater part of the body, we speak of it as psoriasis 
universalis. Not infrequently these cases bear a striking 
resemblance to dermatitis exfoliativa. 

Every case of psoriasis does not exhibit all these vari- 
eties, because the disease may stop short at any period of 
its evolution. But in any case there is apt to be a num- 
ber of variously sized lesions. Whatever the size of the 
patch may be, it will always be observed that the redness 
extends a little beyond the scales. The amount of the 
scaling will vary. Sometimes the scaling will be but 
slight ; sometimes it will be so abundant that it will heap 
up into such crust-like masses as to suggest the adjective 
rupioide. The scales are constantly being shed, and as 
constantly renewed. They may be readily scraped off 
with the nail, and if this is carefully done a delicate glis- 
tening membrane will be exposed, under which will appear 
dot-like red points. That is, we have removed the epi- 



PSORIASIS. 457 

dermis and exposed the mucous layer of the skin, the red 
points being the tops of the slings of blood vessels of the 
papillae. This is thought by some to be characteristic of 
psoriasis, but with care it may be produced in other 
diseases. 

The color of the scales is silvery-white or grayish. 
Darker scales are due either to the deposition of dust, or 
the admixture of blood. The color of the patch will vary 
from a pinkish-red to a dark-red, the darker color being 
seen upon the legs, where the color of all lesions is darker 
on account of the partial stasis in the return flow of blood. 
The disease is always a dry one, there being absolutely 
no discharge feature in its course. The patches are 
sharply defined, but so little raised that they can be 
nearly all scratched away. 

While psoriasis may occur anywhere on the body, and, 
as we have seen, may become universal, its most frequent 
locations are the extensor surfaces of the limbs, elbows, and 
knees, or rather the face of the tibiae just below the knee, 
and the scalp. It may occur upon the first two locations 
alone. When it occurs on the scalp careful examination 
will generally show some lesion elsewhere on the bodv, and 
we will usually find a little patch in front of the ears, and 
very often there will be a red scaly line on the forehead 
just in front of the hair-line, a feature that is as striking 
and as characteristic of psoriasis as the corona veneris is 
of syphilis. The hair does not fall, as a rule. In some 
cases, however, we may have transient or permanent 
alopecia. The whole scalp may be covered with a con- 
tinuous patch, or distinct scaly patches may form as on 
the body. In any event the border of the patch will be 
sharply defined. 

The palms and soles are very rarely the seat of the dis- 
ease, and then only as part of general psoriasis. It is 
true that a few cases have been reported in which it has 
been said even to be located upon one hand alone, and this 
by competent observers ; but the probabilities are all in 
favor of such cases having been either syphilis, which is 



458 DISEASES OE THE SKIN. 

most likely, or squamous eczema. The disease is bilateral 
and sometimes may show a decided tendency to sym- 
metry. 

In old inveterate cases there may be considerable thick- 
ening of the skin, a feature that is usually wanting, and 
fissures may form about the joints that may be painful 
and bleed. This may also occur on the scrotum, or the 
trunk where the skin is in folds. 

The nails are affected in some cases, becoming opaque, 
lustreless, furrowed transversely, discolored, and some- 
times cracked ; while they are raised from their beds by 
the accumulation of scales underneath them. All the nails 
are rarely diseased at the same time ; usually it is but one 
or two nails on each hand or foot. Sometimes the disease 
is limited to a strip along the side of one nail. 

There is no constitutional disturbance in this disease, 
the patients usually being in as good health as the majority 
of mankind. Sometimes they will have pains in the joints 
that are regarded as rheumatic by some, and as neurotic 
by others. Itching is very often an annoying symptom. 
Sometimes it is entirely wanting. 

The course of the disease is variable. Although it is 
always chronic, it presents at times acute symptoms. Re- 
lapses are the rule to which there are few exceptions. In 
some cases the skin will be entirely free from all trace of 
the disease for months or years. In most cases this free- 
dom is only partial ; even though the patient thinks he is 
clean, some little spot will be discoverable. The duration 
of each patch is also variable. It may disappear in a few 
weeks or remain for months. Most cases are better in 
summer, to become worse in winter. When the patches 
disappear they do so completely, though a slight amount 
of scaling may be present for a short time. In a few very 
rare cases a chronic psoriatic patch has become papillo- 
matous and then epitheliomatous. 

Etiology. Various theories have been advanced in 
the etiology of psoriasis, and some facts have been estab- 
lished by our study. We know that the disease is hered- 



PSORIASIS. 459 

itary in a number of cases. Greenough 1 found the pro- 
portion as high as one-third. It may occur at auy age. 
Kaposi has reported a case at eight months of age, and 
Riehl 2 one at thirty-eight days. It usually is a disease 
of early adult life, making its first appearance before the 
thirtieth year. It is rare after the fiftieth year. It af- 
fects both sexes, and all conditions of life. These things 
we know. 

While the majority of patients seem to be in the best 
of health, sonie are rheumatic or gouty. A lowered con- 
dition of the general health seems, in some cases, to favor 
an outbreak either of a primary attack or of a relapse. 
Thus it is no uncommon thing to see the disease in women 
grow worse during pregnancy or lactation. Mal-assimi- 
lation or digestive disorders also seem to aggravate or 
provoke the disease, Hardaway even affirming that he has 
known the inordinate eating of oatmeal to cause the dis- 
ease, while Gowers 3 reports cases produced by the inges- 
tion of borax as a medicine. Polotebnoff i has written an 
elaborate thesis to show that the disease is a vasomotor 
neurosis, affirming that in a majority of cases there will 
be found evidences of either trophic or vasomotor dis- 
turbances, or a history of more or less profound nervous 
troubles either in the patient or his family. A number 
of cases following fright or nerve-shock have been re- 
ported. In the Vierteljahrcsschrift f. Dermal, u. Syph. for 
1878, Lang brought out his parasitic theory, and in No. 
208 of Volkmann's Sammlung Minische Yoiirficjc the the- 
sis is further elaborated, the fungus being represented by 
illustrations. He has found some support from other 
observers, but the theory has not gained general credence. 

It is a well-known fact that an injury to the skin of a 
psoriatic, such as a pin-scratch, will determine the location 
of a patch of psoriasis. 

1 Boston Med. and Surg. Joum., 1885, cxiii., !§?>.] 

2 Monatshefte f. prakt. Derniat., 1895, xxi., 283. 

3 Lancet, October 24, 1884. 

4 Monatshefte f. prakt. Dermat, 1891, Ergiinzungsheft, No. 1. 



460 DISEASES OF THE SKIN. 

Pathology. Pathologists by no means agree in their 
teachings as to the histology of psoriasis. By some it is 
regarded as inflammatory, while others believe it to be a 
keratolysis, or an anomaly of cornification in which an 
imperfect corneous layer is formed. Some teach that the 
process begins in the rete, and the changes in the corium 
are secondary ; while others hold the reverse view. Lang 
names his parasite epidermidophyton, and describes it as 
composed of mycelia and spores, either disseminated or 
in groups, which are so delicate as to be found only with 
very high powers. 

Diagnosis. A typical case of psoriasis presenting 
round or oval, variously sized, pinkish red, dry patches 
covered with thick silvery-white scales, scattered more or 
less generally over the body, but showing a marked 
preference for the extensor surfaces of the extremities and 
especially of the elbows and knees, is readily recognized. 
In some less typical cases it needs to be differentiated from 
syphilis, eczema, seborrhoea, dermatitis exfoliativa, lichen 
ruber, and lichen planus, seborrhoeal eczema, and pos- 
sibly from lupus erythematosus. From the squamous 
syphilide of the secondary stage of the disease it differs 
by showing preference for the extensor surfaces of the 
limbs and the posterior surface of the trunk, though there 
are many exceptions to this rule. The syphilide is not so 
scaly ; its red is darker, more raw-ham-colored ; the lesions 
are more infiltrated, giving a more shotty feeling to the 
finger ; they do not itch ; they run a more acute course, 
and are of more uniform size, never exhibiting the patchy 
character of psoriasis. It is usually easy to establish the 
presence of other manifestations of syphilis, such as sore- 
throat, pains in the bones, fall of the hair, and per- 
haps the remains of the initial lesion. The late scaly 
syphilide is never general ; is unsymmetrical, usually 
consisting of one or two groups of lesions that show 
no tendency to affect the elbows and knees. The lesions 
are more raised and prone to leave scars. There will 
also be the history of past syphilides to guide us, and 



PSORIASIS. 461 

an absence of those relapses so common and characteristic 
of psoriasis. 

Eczema squamosum is far more pruritic than psoriasis 
usually is ; the patch is more infiltrated ; the scaling is 
less, the scales being thinner ; exudation can be readily 
induced ; and a history of moisture at some time will be 
found. The patch of eczema is generally less sharply 
defined, and is more apt to shade off into the surround- 
ing skin. If the scales of a psoriatic patch are removed, 
a delicate membrane is left showing red dots — the tops 
of the blood vessel slings in the papillae ; if the same thing 
is done in eczema, a discharging surface will be left. 

Seborrhea may simulate a psoriasis when it occurs in 
patches on the chest, or as thick crusts on the scalp. The 
patches on the chest have a more yellow color and their 
scales a more greasy feel than is the case in psoriasis. On 
the scalp the crusting of seborrhoea does not occur in such 
sharply defined patches, and its crusts are very greasy. 
In either case, if it be one of psoriasis, we will be sure to 
find one or more typical lesions somewhere on the trunk. 

It is quite impossible to differentiate a true case of der- 
matitis exfoliativa at first sight from one of general pso- 
riasis. If it does arise from psoriasis, there will be a 
history of its gradual spread from typical lesions quite 
different from what obtains in true dermatitis exfoliativa, 
which is more rapid in its evolution. Psoriasis is rarely 
so absolutely universal as is dermatitis exfoliativa. Watch- 
ing the case for a time will establish the diagnosis. If 
psoriasis is the malady, it will declare itself after a time 
by the diffused redness clearing up and typical psoriatic 
patches showing themselves. 

Lichen ruber presents small, pointed papules upon the 
trunk at first, and not the large, scaling papules upon the 
extensor surfaces of the limbs of psoriasis. When the 
disease becomes general we will have the history of these 
lesions, and the skin will be more thickened and rugose. 

Lichen planus occurs by preference on the flexor rather 
than the extensor aspects of the limbs, and in the form of 



462 DISEASES OF THE SKIN. 

flat, shining, angular, smooth papules, rather than of 
round, freely scaly ones. The color of its patches is viola- 
ceous and not bright red. If it becomes universal, it 
does so evidently by the springing up of new small lesions 
between the old ones, and not by the peripheral growth 
and coalescence of those already existing. The thicken- 
ing of the skin is also much greater than in psoriasis. 

In the diagnosis from seborrheal eczema, Unna lays 
great stress upon four points : 1. Seborrheal eczema 
spreads from above downward, mostly in the middle line 
of the body, and its lesions are quite stationary in char- 
acter ; while psoriasis begins on the elbows and knees, 
and more speedily affects the w T hole body. 2. There is 
always a history of a seborrhoeal affection of the scalp in 
seborrheal eczema. 3. The scales of seborrhoeal eczema 
are fatty and crumbling, and the patches are yellowish ; 
in psoriasis the scales are white and friable, not greasy, 
and the patches are bright red. 4. The proneness of the 
patches of seborrhoeal eczema to form bow-shaped figures, 
or rings more or less broken. Psoriasis may be circinate, 
but the margins of the figures are not so narrow and not 
follicular as they may be in seborrhoeal eczema. 

Treatment. Though external treatment alone will 
remove the evidences of psoriasis upon the skin, producing 
a cure of the disease — if that may be said of a disease that 
is almost sure to relapse — we generally can procure more 
prompt results by a combination of internal and external 
remedies. The first inquiry in all cases should be made 
as to the general condition of the patient, and we should 
endeavor to establish in him as perfect a state of health 
as is possible. A restricted diet certainly does have a 
good deal of influence in causing an amelioration of the 
disease. No hard and fast lines can be set in this respect. 
In the service of Prof. George Henry Fox, who is a strong 
advocate of dieting in skin diseases, I have seen some pa- 
tients improve under a strictly vegetable diet, and others 
do equally well on a dietary composed largely of milk and 
animal food. A stout, eA^idently overfed, plethoric patient 



PSOBIASIS. 463 

will be benefited by cutting off all, or nearly all, meat. 
In this class of patients it is a good plan to insist upon a 
milk diet for a few days. An anseruic, underfed patient 
will, on the other hand, improve under a more liberal 
dietary. Alcoholics, and especially malt liquors, should 
be interdicted in all cases, as well as rich gravies and 
highly spiced foods. 

Besides these general measures we have a number of 
drugs that have gained a more or less well-earned reputa- 
tion as remedies for psoriasis, though it must be confessed 
that they are more or less empirical remedies. 

Arsenic would be named, without doubt, by most gen- 
eral practitioners as the remedy for psoriasis. It does do 
good in this disease, but at the same time it is not to be 
considered as a true specific. In acute cases it aggravates 
the disease and should never be given. In chronic cases 
that have proved very stubborn it may be tried, and some- 
times it will produce a speedy cure. The vast majority of 
cases will do quite as well without it. It may be given 
in the form of Fowler's solution with or without the wine 
of iron, and administered in water three times a day after 
meals. The initial dose for an adult should be about 
three drops, and the amount should be gradually increased 
until the limit of toleration is reached. Crocker thinks 
that the efficiency of this form of arsenic is enhanced by 
the addition of half a drachm of the tincture of lupulus to 
each dose. The Asiatic pill is the favorite mode of using 
arsenic in Vienna. It is composed, according to Kaposi, 
of— 

R • Pulv. ac. arseniosi, 75 

Pulv. piperis nigne, 6 

Gummi acacia?, 1 50 

Pulv. althae. rad., 2 

Aqua 3 , q. s. 

Div. iu pil. no. c. M. 

One pill is given after meals, and the dose is increased 
gradually every four or five days until ten or twelve are 
taken a day, unless some constitutional disturbance is 



464 DISEASES OF THE SKIN. 

caused before then. The method of increase is by first 
giving one pill after each meal ; then two pills after break- 
fast, and one after the other two meals ; and then two after 
breakfast, two after the midday meal, and one in the even- 
ing, and so on. Or we may make use of the tablet tri- 
turates of arsenious acid with piperina, giving those 
containing one-twentieth of a grain of the arsenic in the 
same manner as the Asiatic pills. Any other preparation 
of arsenic may be used. Hypodermatic injections of 
arsenic have been employed with success, but it would be 
hard to induce an American patient to endure this method. 
The administration of the drug must be persisted in for a 
long time, and it may prove curative by itself. 

Alkalies that act as diuretics are often very helpful, 
quite apart from any indication for their use on account 
of gout or rheumatism. A beginning psoriasis, or even a 
case of some duration, will be favorably influenced by the 
administration of the acetate or citrate of potassium in 
fifteen-grain doses before meals, well diluted, and followed 
by drinking half a glass of water. The undoubted efficacy 
of large closes of the iodide of potassium, as recommended 
by Haslund, 1 may depend in part, at least, upon its diu- 
retic action. He gives the salt in increasing doses so 
that as much as 600 grains have been administered to 
one patient during the day. When assistant physician 
to the New York Skin and Cancer Hospital, on Dr. G. 
H. Fox's division, I tried Haslund's plan in several 
cases. They certainly were greatly benefited. The ob- 
jections to this method are the expense of the drug and 
the danger of the sudden production of poisoning, shown 
by palpitation of the heart, severe headache, and faint- 
ness, and necessitating either the keeping of the patient 
in a hospital or under the constant attendance of a phys- 
ician. 

Turpentine oil is highly commended by Crocker as fol- 
lows : It may be given in capsule, or, preferably, as an 
emulsion rubbed up with mucilage of acacia. The initial 

1 Vierteljahr. f. Derm. u. Syph., 1887, xiv., 677. 



PSORIASIS. 465 

dose is ten minims three times a clay after meals. It may 
be increased by five or ten minims at a dose until the pa- 
tient, if tolerant of it, is taking thirty minims three times 
a day. Barley-water must be freely drunk during the 
day to prevent any bad eifect on the kidneys, and the 
last dose of the turpentine should be taken not later than 
six or seven o'clock in the evening. Dyspepsia and irri- 
tability of the urinary organs contraindicate its use. The 
same authority advocates the use of salicylate of soda in 
fifteen-grain doses three times a day after meals, or salicin. 

The wine of antimony in five- to ten-minim doses is 
recommended by Mr. Malcolm Morris as efficacious in 
acute cases. 

Chrysarobin by the mouth, one-sixth of a grain in 
sugar of milk three times a day, and increased to one or 
two grains at a dose, acts well in some cases, but is very 
apt to cause so much nausea and vomiting as to compel 
its discontinuance. 

Polotebnoff, believing the disease to be a neurosis, ad- 
vocates the use of bromide of potassium, and of ergot. 

External treatment. Before making any application to 
the psoriatic skin the scales must be removed by bathing 
with soap and water, or by warm alkaline baths. Some- 
times bathing followed by inunctions of the skin with 
simple oil, or vaseline, combined with attention to diet, 
will produce a cure. These measures should be tried first 
in all newly beginning cases. In some cases there will 
be well-marked eczematous conditions. Then we must 
use remedies applicable to that disease. Generally Ave 
must resort to more stimulating remedies. The most 
useful and most promptly curative external remedy is 
chrysarobin (chrysophanic acid). The objections to it 
are its tendency to produce an acute dermatitis and its 
permanent staining of everything with which it comes in 
contact. These unpleasant effects may be in part over- 
come by combining the drug with flexible collodion or 
traumaticin, but only in part. The dermatitis is always 
most marked upon those parts in which there is laxity of 
30 



466 DISEASES OF THE SKIN. 

the skin, and if it is nsed on the face it is prone to pro- 
duce great swelling about the eyes. Care must be taken 
not to get it in the eyes, as it causes violent conjunctivitis. 
These effects should make us very cautious about using it 
on the scalp, and prevent its use on the face. 

The most active form in which to use the drug is in an 
ointment as of lard, lanolin, or vaseline. Bassorin and 
plasment are excipients that have the merit of not being 
greasy, and of being readily and entirely removed by 
means of water. Flexible collodion or traumaticin, the 
liquor gutta-perchse, are good excipients. 

The strength of chrysarobin should not exceed one 
drachm to the ounce, as a rule, though in exceptional cases 
it may be used in greater strength. Its activity is in- 
creased by the addition of salicylic acid (3 per cent.), and 
then it is best /to use it in a lower percentage, even 5 per 
cent, being active enough. An alkaline bath before using 
the chrysarobin increases its potency. If we use an oint- 
ment, it should be thoroughly rubbed in once a day after 
the scales are removed. If our vehicle is bassorin, plas- 
ment, collodion, or gutta-percha solution, the spots should 
be painted over as often as the film left by the application 
falls. The patient should always be warned against get- 
ting the drug in his eyes. A favorite formula of Dr. 
George H. Fox is the following : 

R. Chrysarobin., \ „ 

01. coding J aa A paits - 

Ac. carbolici, 1 part. 

Ac- oleic, 50 parts. M. 

If the chrysarobin produces too great a reaction, it 
must be stopped, and the skin treated with vaseline and 
starch powder, or an alkaline wash. The action of the 
drag upon the skin is peculiar. It stains the skin about 
the patches a mahogany-red, while the patches become 
smooth and white. It discolors the nails and the hair, but 
after a time the staining disappears. Not so the staining 
of the clothing, which is permanent. It is said that it can 



PSORIASIS. 467 

be somewhat lessened by soaking the clothes in plain water 
before using soap in washing. 

Before chrysarobin was discovered much reliance was 
placed on the ointment of the ammoniate of mercury. It 
is still a reliable remedy, but it cannot be used over the 
whole body in a general psoriasis on account of the danger 
of absorption of the mercury. It is the pleasantest and 
promptest application to the scalp and face, and can be 
used there while chrysarobin is used on the rest of the 
body. Other mercurial ointments, such as that of the 
vellow oxide, and a dilute ointment of the nitrate, may 
be used. Lang has found the bichloride of mercury in 
collodion in J to J per cent, strength a good application. 
It would probably be an unsafe one in a case of any extent. 

Tar is another old and reliable remedy, still much used 
in France. It may be employed in an ointment, or oil, 
or dissolved in alcohol. The oil of cade, oil of birch, or 
pure tar may be used in the strength of half a drachm to 
four drachms to the ounce. In Paris the following is 
sometimes used : 

Sapo. viridis, 5 " M. 

This is to be rubbed in at night, the patient is to sleep 
in a flannel gown, and wash the stuff off in the morning. 
Kaposi recommends the following : 



R. 01. rusci, 


50 parts 


Etheris sulphuris, \ 
Alcoholis, J 


aa 75 " 


Filter and add 




01. lavandulse, 


2 " 



M. 

Tar in any form is a dirty application, and is prone to 
produce inflammation of the skin, as well as toxic symp- 
toms. Pyrogallol (pyrogallic acid) is efficacious, but can 
only be used in cases in which the eruption is not exten- 
sive, on account of its poisonous action when absorbed. 



468 DISEASES OF THE SKIN. 

It may be used in the strength of about 10 per cent, in 
ointment. It stains the skin, but causes less inflamma- 
tory reaction than chrysarobin does. 

Thymol was introduced by Crocker. It may be used 
as an ointment or lotion in the strength of 15 grains to 3 
drachms to the ounce. As it is colorless and of pleasant 
odor it is suitable for use on the face. The same author- 
ity advocates the use of turpentine locally. He uses the 
oleum pini sylvestris with sufficient oil of lavender or es- 
sence of lemon to cover its odor. If used undiluted, the 
skin must be smeared with vaseline to prevent its crack- 
ing. It is better to use it diluted with olive oil, 3j of oil of 
turpentine to ovij of olive oil, the proportion of the oil 
of turpentine being increased as the skin becomes accus- 
tomed to it. The addition of oil of cade or oleum rusci 
to the mixture increases its efficacy. 

Salicylic acid, 5 to 20 per cent, strength, will remove 
the scales, and in some cases will prove curative. The 
soap treatment, as described in chronic eczema, is of great 
value in some chronic circumscribed cases. Sulphur oint- 
ment, oleate of copper, "rufigallic " acid, 10 per cent, in 
ointment, and resorcin, have all done well in some cases. 
Hydracetine, anthrarobin, and aristol are among the latest 
remedies, but have not proved themselves as active as 
some of the older ones. 

Gallacetophenone in 5 to 10 per cent, strength as oint- 
ment or dissolved in collodion may be tried, but is not as 
good as chrysarobin. 

Some patients have found benefit from the use of nat- 
ural mineral waters at spas. It is possible that much of 
the benefit so obtained is from the prolonged and regulated 
bathing. Wearing rubber clothing next the skin, or 
with a fine piece of muslin between the rubber and the 
skin to avoid the production of eczema by the rubber, will 
soften and remove the scales, and hasten the disappear- 
ance of the patches. 

Pkognosis. A cure of psoriasis may be promised with 
a fair degree of certainty as far as the removal of the erup- 



PURPURA. 469 

tion then out is concerned ; but no promise can be made 
that the disease will not relapse. In this respect pso- 
riasis resembles rheumatism and gout. While most re- 
lapses are readily removed in the course of a few weeks, 
in some cases one or more patches will be remarkably 
obstinate. 

Psorospermosis Follicularis Cutis is the name given by 
French writers, notably by Darier, 1 to a disease of the 
skin cases of which had previously been reported under 
the names of lichen spinulosum (Hutchinson), ichthyosis 
sebacea cornea (Wilson), acne sebacea cornea (Guibout), 
ichthyosis follicularis (Lesser), keratosis follicularis (Mor- 
row and White), acne cornee (Leloir and Yidal), caco- 
trophia folliculorum (T. Fox), and sauroderma. The title 
psorospermosis was given by Darier because he believed 
that he had found certain parasites belonging to the order 
of protozoa, which have been named psorosperms in causal 
connection Avith the disease. (For description of the dis- 
ease see Keratosis follicularis.) 

Pterygium (Te 2 r-i 2 j r -i 2 -u 3 m) is simply an overgrowth of 
the normal nail-fold at the proximal end of the nail so 
that it covers, to a greater or less extent, the lunula. It 
may be cut off. 

Purpura (Purp r -u 2 r-a 3 ). Synonyms : Hsemorrhoea pete- 
chialis ; (Ger.) Blutfleckenkrankheit. 

Symptoms. By this term is meant a hemorrhage into 
the skin which is not caused by direct traumatism. It is 
always readily recognized by the red, purple, or blue- 
black color that it causes, which cannot be made to dis- 
appear by pressure. The hemorrhage may take place 
into any part of the skin ; into the subcutaneous tissues ; 
or into any of the glandular apparatus of the skin. It 
occurs with suddenness, and produces variously sized 
lesions to which certain names have been applied. When 
they are small, from pin-point-size to perhaps an inch in 
diameter, they are called petechice. When occurring in 
1 Ann. de derm, et syph. ; 1889, x. } 597, 



470 DISEASES OF THE SKIN. 

the form of more or less long streaks they are called 
v ibices. Large bruise-like lesions with more or less swell- 
ing are ecchymoses. Blood tumors of all sizes are ecchy- 
momata or hcematomata. The color of all purpuric lesions 
depends upon their age. When first formed they are 
bright red, claret, or purple. Before disappearing they 
pass through various shades of color such as are seen after 
an ordinary bruise, becoming blue-black, greenish -black, 
or brownish. These changes are due to the gradual ab- 
sorption of the effused blood and the hsematin deposited 
from the blood globules. There is no definite time for 
complete absorption to take place, but eventually no trace 
is left of the previous hemorrhage. 

If the extravasation of blood takes place into the hair 
follicles, we will have papules formed. If between the 
layers of the epidermis, hemorrhagic bullae may result. 
Hemorrhage into sweat glands will give rise to hsemati- 
drosis. As complications of other dermatoses hemorrhage 
may occur, as in urticaria, pemphigus, and eruptive fevers, 
but these should not be elevated into special varieties of 
purpura. 

There are three varieties of purpura, namely, purpura 
simplex, purpura hemorrhagica, and purpura rheumatica. 
It is convenient for us to preserve these varieties for a 
time, though the results of the latest studies seem to indi- 
cate that the second variety is but a more developed form 
of the first, cases of simple purpura having been seen to 
run into the hemorrhagic form. By Crocker and others 
the third variety is regarded as a form of erythema exu- 
dativum. It, too, has been seen to run into the hemor- 
rhagic form. 

Purpura Simplex is the most common variety, and usu- 
ally takes the form of petechia, the lesions being round or 
oval, or irregular in shape, or even circinate. Duhring 
describes a case of the circinate form, as does Stelwagon. 1 
The lesions appear suddenly, generally without antecedent 
symptoms, and often at night. Like other varieties of 
1 Journ. Cutan. and Gen.-Urin. Dis., 1887, v., 369. 



PURPURA. 471 

purpura, the lower extremities are the most common seat 
of the eruption, especially their flexor aspects, but any 
part of the skin may be attacked, as also the mucous 
membranes. Crocker affirms that in children the lesions 
appear first upon the neck and upper part of the back. 
The lesious appear in crops, and most often are symmet- 
rical. There may be but a single outbreak, and the 
whole disease may be at an end in a week or two. But 
it may be prolonged for many Aveeks by a succession of 
outbreaks. There is usually no constitutional disturb- 
ance, and the only things the patient complains of are 
the spots, and perhaps some itching. There may be las- 
situde, malaise, and slight elevation of temperature. Ee- 
covery is the rule. Exceptionally purpura simplex passes 
over into 

Purpura Hcemorrhagica. This form is also called mor- 
bus maculosus Werlhoffii and land scurvy. It usually 
begins as such, and is heralded by pronounced malaise, 
headache, and perhaps convulsions. It begins without 
prodromata. It differs from the previous variety by the 
more extensive hemorrhages that take place, ecchymoses 
forming rather than petechias, and by free bleeding from 
all the mucous membranes — nose, mouth, stomach, ure- 
thra, rectum, vagina. These are so copious and uncon- 
trollable at times that the patient will literally bleed to 
death in a few hours. Sudden death may also be caused 
by hemorrhage into the meninges and brain. An ex- 
cellent study of this fulminating form of purpura has 
been made by Lockwood. 1 In his case there was a rise 
of temperature to 106.2° F. just before death, and the 
patient died in about sixty hours from the onset of the 
disease. He collected thirty cases, in thirteen of which 
the patients died from acute anamiia, internal hemorrhages, 
or septic infection, the shortest duration of any one case 
bein£ seven hours ; in eio;ht cases death was due to cere- 
bral hemorrhage ; and in four cases the patients were 
pregnant. Happily all eases of hemorrhagic purpura are 

1 Medical Eecord, 1891, xxxix., 155. 



472 DISEASES OF THE SKIN. 

not fatal. In them the bleeding is moderate in amount, 
and the patient is gradually restored to health. Relapses 
may occur. 

Purpura Fulminans is the name applied to those very 
grave cases of purpura in which the patient dies in a short 
time. It is a form of purpura hemorrhagica. It may 
aifect several members of the same family, which suggests 
its infectious nature. It has followed scarlatina. 

Purpura Rheumatica. This is also called peliosis rheu- 
matica. It resembles purpura simplex in every way, ex- 
cepting that the outbreak of the eruption is preceded or 
followed by pain in the joints accompanied by swelling, 
the malaise is more marked, and there is often rise of tem- 
perature. The eruption is often most abundant about the 
joints. The acute symptoms subside in two or three days, 
but relapses are frequent. True rheumatism may be pres- 
ent at the same time. Valvular heart lesions have been 
reported to occur after this variety of purpura, even with- 
out true rheumatism. Rarely this variety may pass over 
into the hemorrhagic form. 

Etiology. Many causes have been assigned to ac- 
count for the occurrence of purpura. We know that it 
may occur at any period of life, in both sexes, and in the 
most varying conditions of health. We meet with cases 
in the spring and autumn, in weather that is damp and 
cold. There is no doubt that purpura occurs as a symp- 
tom in different diseases and cachexia? ; after the ingestion 
of certain drugs, and under other circumstances too 
numerous to catalogue here. Here we can readily sur- 
mise that one or both of two things have occurred, 
namely : a change of the blood itself that allows of its 
passing through the walls of the vessels ; or a change in 
the vessel walls themselves that permits the blood to 
pass through them. Purpura has been noted after the 
loosening of some artificial support to a part of the body, 
such as a tight bandage worn for a long time. It occurs 
not infrequently in old age. In both these conditions it 
is due to a weakening of the tone of the vessels. In the 



PURPURA. 473 

former case matters right themselves in a few days — a 
happy conclusion that cannot be anticipated in the latter 
case. Weakness of vascular walls may also be the cause 
of those somewhat rare cases of purpura without cachexia 
seen in infants. Other cases of purpura are due to small 
thrombi lodging in the smaller vessels. Some cases seem 
to be due to vasomotor or trophic nerve action causing 
either sudden alterations in the calibre of the vessels or 
degenerations in their walls. Recurring purpura has 
been noted about the point of greatest pain in neuralgia. 

The microbian and infectious origin of purpura is stoutly 
defended by some authorities. Some authorities believe 
that purpura occurring in an infectious disease is due to 
micro-organisms. Letzerich * published a brochure on 
this subject in 1889, in which he described the " bacillus 
purpura? hemorrhagica? Letzerich " as the cause of the 
disease. This has sharp angles and edges, is readily cul- 
tivable, and pure cultures injected into rabbits give rise 
to hemorrhages either spontaneously or on slight trauma. 

Diagnosis. The diagnosis of purpura is easily made. 
No other disease produces bright-red, slightly elevated 
lesions, the color of which cannot be made to disappear 
under pressure. From flea-bites they are distinguishable 
by the absence of a central punctum. Purpura hemor- 
rhagica bears a close resemblance to scurvy, but in the 
latter a dietary deficient in vegetables is a marked etio- 
logical factor ; there are also greater prostration, swelling 
of the gums, loosening of the teeth, and brawny swelling 
of the limbs. It is possible that further investigations of 
scurvy may show that it is but a form of purpura hemor- 
rhagica that has been modified by diet. 

Treatment. In simple purpura there is not much to 
be done except to put the patient in as good a hygienic 
condition as possible and relieve symptoms. In peliosis 
rheumatica and purpura hemorrhagica the patient should 
be kept absolutely quiet in bed, his diet should be of the 
most nutritious and easily assimilable kind, and ergot and 

1 Monatshefte f. prakt. Dermat.,, 1889, ix., 312. 



474 DISEASES OF THE SKIN. 

iron administered. Of course, if there is hemorrhage 
from the nose, vagina, or other mucous cavity an effort 
must be made to stop the flow by means of a tampon, ice, 
hot water, or any method that experience has proved use- 
ful. Ergotine may be employed hypodermatically ; and 
turpentine ; dilute sulphuric acid ; nitrate of silver in pill- 
form J- to ^ of a grain three times a day ; and other as- 
tringents have been found useful. Letzerich recommends 
for the local treatment of bleeding from the gums — 

R . Tinct. ratanhise, 10 parts. 

Tinct. iodini, 5 " M. 

of which 10 drops are to be put in a wineglassful of water. 
For this purpose other astringents, as tannin, alum, and 
the like may be used. 

Prognosis. From the beginning of a case it is not 
possible to say how it will turn out. We should there- 
fore be very guarded in our prognosis. Most cases met 
with terminate favorably. Some apparently desperate 
cases recover. 

Pustula Maligna. Synonyms : Anthrax ; Malignant 
pustule ; (Fr.) Charbon. 

This is a disease of cattle, sheep, and horses, in which 
it is called splenic fever, and is due to local inoculation 
with the bacillus anthrax, often through the agency of 
flies. If the bacillus gains access to the internal organ- 
ism, it produces a rapidly fatal general disease with no 
skin lesion. In the human the exposed parts — face, 
hands, and neck — are the most frequent sites of the dis- 
ease. In a day or two after inoculation the patient notices 
a burning or itching of the affected part and the formation 
of a livid-red papule upon which a bulla or pustule soon 
forms. This ruptures, the red spot changes into a black 
gangrenous eschar, the parts around it become indurated, 
oedematous, of dusky red hue, and studded with small 
vesicles or pustules. There is marked involvement of the 
lymphatics, and enlargement of the neighboring glands 



RHINOSCLEROMA. 475 

that may suppurate. In favorable cases the slough 
separates, and healing by granulation takes place. In 
fatal cases the gangrenous process extends rapidly, symp- 
toms of septic infection declare themselves, and the patient 
succumbs to the disease in from two to eight days. In 
all cases there is more or less constitutional disturbance. 

Diagnosis. The diagnosis of malignant pustule is 
made mainly by the rapidity with which the disease de- 
velops ; the presence of the gangrenous patch with the 
hard indurated tissues about it ; and the severity of the 
constitutional symptoms. The finding of the bacillus will 
verify the diagnosis. 

Treatment. The total excision of the diseased patch 
by means of a free incision is the most radical and effec- 
tual treatment for the disease. Injection of iodine or a 5 
per cent, solution of carbolic acid under the eschar are 
good methods of treatment. The hyposulphite or sulphite 
of soda, and large doses of quinine, are worthy of trial. 

Quinquaud's Disease. See Folliculitis decalvans. 

Radesyge. See Lepra. 

Raynaud's Disease. See Dermatitis gangrenosa. 

Red Gum. "An obsolete term for various transitory 
eruptions in teething children." (Foster.) Commonly 
this is miliaria rubra. 

Rheumatokelis. A term applied by Fuchs to purpura 
occurring with rheumatism. 

Rhino-phyma (Ri 2 n-o-fi'-ma 3 ) is the term used to desig- 
nate that form of hypertrophic rosacea in which pendu- 
lous tumors develop on the nose. These may attain so 
great a size that they hang down over the mouth. See 
under Rosacea. 

RhinoscleromatErn-o-skhrr-o'ma 3 ). Synonyms: (Fr.) 
Rhinosclerome ; (Ital.) Rinoscleroma ; Perisarcoma. 

Symptoms. This is an exceedingly rare form of dis- 
ease that was first described by Hebra and Kaposi. It 



47G 



DISEASES OF THE SKIN. 



affects almost exclusively the nose and its mucous mem- 
brane, and assumes the form of flat or slightly raised, 
sharply defined, isolated or confluent, very hard, lobulated, 
elastic plates, tumors, or nodes which are painful on pres- 
sure. These lesions are located in the skin or mucous 
membrane of the septum of the nose, or in the alse and 

Fig. 56. 




Rhinosclerorua. 



the neighboring parts of the upper lip. They can be 
raised from the underlying parts, but the skin is so in- 
filtrated that it can move only with the growths. The 
color of the skin may be normal, or bright or dark brown- 
ish-red. They may look like a keloid or hypertrophied 
scar. The contiguous skin shows no abnormalities what- 
soever. The epidermis over the growths often shows 
rhagades from which exude a viscid secretion which dries 
into yellowish adherent scabs. 

The disease begins as a thickening and hardening of the 
septum of one or both alse without inflammatory reaction 
or pain. Slowly the nose becomes deformed, broad, and 
flat, and at last by progressive thickening of both septum 



RHINO SCLER OMA . 477 

and alse the nostrils become occluded. The process may 
involve the lips so that the opening of the mouth becomes 
greatly lessened, and may affect the gums. More fre- 
quently it proceeds backward along the nostrils on to the 
velum palati. The growth shows no tendency to ulcera- 
tion or retrograde metamorphosis. At the most superficial 
parts excoriations occur. Late in the disease the teeth 
may loosen and fall out, and the gums may atrophy. 
The disease begins in some cases in the pharyngeal vault. 
The epiglottis and larynx may be involved in the process, 
and aphonia, suffocative or epileptic-like attacks may oc- 
cur. There is no constitutional disturbance, and the only 
subjective symptoms are those of discomfort on account of 
the interference with respiration. The disease is steadily 
progressive ; shows no tendency to recovery ; and recurs 
rapidly when the diseased parts are cut away. 

Etiology. All conditions of men are affected, and 
both sexes with about equal frequency. It usually begins 
between the fifteenth and fortieth years. It is most fre- 
quent in warm climates, and is specially prevalent in 
Austria and Russia. A bacillus has been found in the 
tissues by Frisch that is regarded as the cause of the dis- 
ease. It is described as short, thick, ovoid, capsulated, 
in free groups and in cells. 

Diagnosis. The location upon the nose and upper lip 
alone, the ivory-hardness of the growths, and their pro- 
gressive course without tendency to ulceration or soften- 
ing, will establish the diagnosis as against syphilis, epithe- 
lioma, and sarcoma. Keloid rarely occurs upon the nose, 
and never runs the characteristic course of rhinoscleroma. 

Treatment. Treatment is very unsatisfactory. The 
growths may be excised or curetted away, but neither pro- 
cess will assure against a relapse. The nostrils may be 
kept open by means of sponge-tents and the like. Bes- 
nier x recommends boring into the tissues with points of 
chloride of zinc for the purpose of giving passage to air, 

1 Ann. de derm, et svph., 1891, ii. , 603. 



478 DISEASES OF THE SKIN. 

Pyrogallic acid, 10 per cent, in vaseline, has been recom- 
mended as of value. 

Prognosis. The prognosis is bad. The disease is 
progressive, and threatens life by suffocation on account 
of involving the larynx. 

Ehus-poisoning". See Dermatitis venenata. 

Ringed Hair. See Canities. 

Ringskurv. See Trichophytosis. 

Ringworm. See Trichophytosis. 

Rissopola Lombarda. See Pellagra. 

Ritter's Disease. See Dermatitis exfoliativa neonato- 
rum. 

Rodent Ulcer. See Epithelioma. 

Rosacea (Pos-a'-ce-a 3 ). Synonyms : Acne rosacea ; 
Gutta rosacea seu rosea ; Acne erythematosa ; (Fr.) Acne 
rosee, Couperose, Rosacee, Rosee ; (Ger.) Kupferrose, 
Kupferfinne, Kupfrigegesicht. 

A chronic disease of the skin, limited in most cases to 
the middle third of the face from above downward, and 
characterized by a diffused or patchy redness made up of 
dilated capillaries. 

This disease is very commonly called acne rosacea, but 
inasmuch as the papules that often occur with the disease 
are not true acne pustules, it is best to drop the " acne " 
from its title. 

Symptoms. Posacea is one of the more common skin 
diseases, and is peculiar in affecting, with few exceptions, 
only the middle third of the long diameter of the face, the 
forehead, nose, and adjacent portions of the cheeks, and 
the chin. The nose may be affected alone, and in many 
cases the forehead escapes entirely. The disease has three 
forms or stages. The first consists in a simple redness of 
the affected skin with more or less well-marked dilatation 
of the capillaries. In the second stage there is an added 
element of superficial papules and pustules, and perhaps 



ROSACEA. 479 

nodules. In the third stage there is marked hypertrophy 
of the skin. The process may stop at any stage. An oily 
seborrhcea may complicate the disease, Unna even claim- 
ing that his seborrhoeal eczema is the first stage of all 
cases of rosacea. 

The first stage varies in degree. At first there may be 
faint flushing of the skin, as after the ingestion of hot 
fluids, exposure to cold, and the like. This being re- 
peated, permanent dilatation of the capillaries takes place. 
The dilated capillaries are not evident all over the patch. 
The greater part of the patch may present an even red- 
ness. The border of the patch is ill-defined, and no 
matter how fiery red the color may be the skin feels cool 
to the touch. This is because the congestion is passive on 
account of a sluggish circulation. In some cases, how- 
ever, there may be but little general redness, only a num- 
ber of dilated capillaries. These telangiectases are best 
seen on the nose. In some cases there may develop a con- 
gestive seborrhcea or even an erythematous eczema, which, 
yielding to appropriate remedies, leaves behind an un- 
doubted rosacea. 

The second stage may develop from the first after the 
latter has lasted a considerable length of time, or be al- 
most coincident with it. The number of papules and 
pustules may be considerable, and the tubercles large. If 
so, the amount of redness will be great. The peculiar 
feature of the pustules is their superficiality. They are 
usually quite small, say of pinhead size, and when pricked 
give exit to but a small drop of thin pus. The tubercles 
are enlarged or clogged sebaceous glands, but all these 
lesions are but secondary to the chronic hyperemia, and 
not primary, as in acne. There may also be comedones 
and true acne scattered over the face. 

While the majority of cases never go beyond the second 
stage, in some cases the continued and excessive hyper- 
emia leads to an increase of connective tissue, and the 
nose, tip and sides, becomes converted into a lobulated 
mass of tissue, sometimes so great as to form pendulous 



480 DISEASES OF THE SKIN. 

tumors hanging down over the mouth. This last con- 
dition is known as rhinophyma. The whole nose is of 
deep-red or purple color, and studded over with crater- 
like openings, leading down into the thickened mass. At 
times ulceration occurs in these crypts and causes addi- 
tional annoyance and deformity from destruction of tissue. 

Fig. 57. 




Rhinophyma. (Lassar.) 

While in the vast majority of cases the middle third of 
the face alone is affected, in some cases the whole face be- 
comes red, and the redness may extend down upon the 
neck. Rosacea is seen at times on the scalp of bald- 
headed persons just above the forehead. 

Etiology. The cause of the disease is probably a 
vasomotor reflex neurosis. Schwimmer regards it as a 
tropho -neurosis ; Unna as a seborrhoeal eczema. It occurs 
in adult life, most frequently after the twenty-fifth or 
thirtieth year, though it may occur even at puberty. 
There is no connection between it and acne. While many 
patients will tell you that they had " pimples " when 



ROSACEA. 481 

young, as many will inform you that they have always 
had a good complexion until the rosacea began. Women 
are more frequently affected than men. Digestive dis- 
turbances are a very common cause of the disease, and the 
trouble may be located either in the stomach, intestines, 
or accessory digestive organs. Drinking of spirits will 
undoubtedly cause it, on account of producing both gastric 
catarrh and reflex dilatation of the facial vessels. The 
inordinate use of strong tea acts in the same way, and 
probably gives rise to as many cases as does alcohol. 
Exposure to the weather or to extremes of temperature 
will cause rosacea without digestive disturbances, but 
when combined with the latter leads on to the most bril- 
liant examples of it. Constipation, menstrual derange- 
ments, anaemia, chlorosis, the menopause, each one has 
been noted in connection with rosacea. The use of cos- 
metics has been followed by it. Various morbid condi- 
tions of the mucous membrane of the nose have been 
found in connection with it. Tight lacing is frequently 
followed by rosacea. 

Pathology. In the first stage there is dilatation of 
the blood vessels in the cutis. In the second stage these 
are more pronounced, and the corium is slightly thickened 
and oedematous in places. In the third stage there is in 
addition enormous hyperplasia of the connective-tissue 
elements of the cutis, and the sebaceous glands are en- 
larged. (Elliot.) 

Diagnosis. When we meet with a case of redness, 
with or without papules, pustules, or tubercles, that is 
limited to the middle third of the vertical diameter of the 
face, it is probably one of rosacea. It differs from acne 
in its limited area, the superficial character of the pustules, 
the absence of comedones, and the capillary dilatation. 
Lupus erythematosus may occur in the same location, but 
in it we do not find the dilated capillaries ; but we do find 
thickening of the skin, adherent scales with prolongations 
from their under side, a sharply defined, slightly raised 
border to the patches, and, if the disease has lasted any 
31 



482 DISEASES OF THE SKIN. 

time, more or less delicate cicatricial tissue. In its early 
stage the diagnosis is not always easy. Lupus vulgaris 
should not confuse us, as in rosacea there is an entire 
absence of the characteristic apple-jelly-like tubercles of 
lupus. The tubercular syphilide may resemble rosacea in 
its second or third stage, but soon it undergoes softening 
and ulceration — processes that do not occur in rosacea. 
Moreover, it is not symmetrical, but occurs in the form of 
groups of tubercles, presents no telangiectases, and evi- 
dences of other syphilides are usually to be found. Ery- 
thematous eczema burns and itches, the skin is somewhat 
swollen and scaly, and feels harsh and leathery. Some- 
times an eczematous condition complicates a rosacea, and 
the latter declares itself only when the former is cured. 

Treatment. In order to treat rosacea successfully we 
must first endeavor to remove the cause. We must in- 
quire as to the condition of the digestive apparatus, the 
manner in which menstruation is performed, exposure to 
heat and cold, and, in fact, ascertain the patient's general 
condition. Then we must address ourselves to the regu- 
lation of any deranged function. We must stop the use 
of alcoholics in any form, and the ingestion of all hot 
fluids, such as tea, coffee, and soup. All these tend to 
produce dilatation of the blood vessels of the face and to 
keep up those conditions we wish to remove. The pa- 
tient's diet should be carefully regulated, and such things 
as pastry and sweets cut off, so as to make digestion as 
easy as possible. Medicinally, tincture of mix vomica, 
the mineral acids, or alkalies are to be administered q. r. n. 
Nux vomica has often seemed to render good service, even 
without there being marked digestive disturbance. Salol 
is a good remedy in many cases of intestinal fermentation. 
Ergot or ergotin proves useful in some cases, either with 
or without uterine disturbances. Ichthyol is commended 
by Unna. The ammonia-sulphate is the preparation to 
use, and it is best given in capsules to cover the taste. 
The dose is three drops two or three times a day. In a 
rather extensive trial of this by me in some sixty cases in 



ROSACEA. 483 

which it was used alone, with no external application, the 
result was unsatisfactory, only one or two cases beiug 
benefited. Ichthalbin has been substituted for ichthyol 
and some good results from its use have been reported. 

The local treatment is important in hastening a cure, 
but is not of itself curatiye in well-marked cases of reflex 
rosacea. The patient must be instructed to protect the 
skin from the action of wind and weather, by either apply- 
ing some ointment, such as yaseline, or a powder, such as 
cornstarch, before venturing out of doors. Then the face 
should be bathed in hot water every night before going to 
bed, the water being as hot as the skin can stand without 
burning, and it should be sopped on for about ten min- 
utes, freshly heated water being added from time to time, 
so as to maintain a uniform temperature. This is benefi- 
cial because the primary dilatation of the vessels caused 
by it is followed by contraction. After the bathing the 
following lotion should be applied : 



R. Zinc, sulphat, \ 
Potass, sulphuret., J 



5J; 3 



Aqua? rosse, ad giv; 100 



M. 



It is, perhaps, as good as any application we can make. 
Van Harlingen gives another good one as folio Ays : 

R. Sulphur, praecipitat., 5J! 6 

Pulv. camphora?, gr. v; 5 

Pulv. tragacanth., gr. x; 1 

Aqua? rosse, \ - - te . t nn 

Liq.calcis/} aa Sj; 10 ° M. 

Instead of lotions, sulphur ointment (oj-oj), or the 
white precipitate ointment may be used, or simply pow- 
dered sulphur. In obstinate cases Yleminckx's solution 
may be used. It is composed as follows : 

R. Calcis, 5iv ; 51 

Sulphur, sublimat., 5J; 10 

Aqua? destillat.j ^x; 100 M. 



484 DISEASES OF THE SKIN. 

Boil together with constant stirring, until the mixture 
measures six fluid ounces, then filter. 

This is to be diluted four or five times at first, and used 
at night only, followed by cold cream in the morning. 
The dilution is to be lessened by degrees. Any of these 
remedies may produce a dermatitis, followed by desqua- 
mation, which is to be desired. For this purpose we may 
use resorcin, 10 to 20 per cent, in vaseline, stopping it 
when the skin begins to peel, when the skin is to be 
dressed with cold cream until the irritation has subsided. 
Then the resorcin is to be used again. Hillairet * recom- 
mends washing the face in the morning with hot water, 
followed by a solution of oxide of zinc, three or four 
grains to the ounce, sopped on for half an hour. Before 
going to bed the following is to be applied to the face : 



R. 



Alcohol, camphorat, 


8 ad 15 


Sulphur, sublimat., 


30 


A quae destillat., 


250 



M. 



After six days this is to be discontinued for a couple of 
days, and then begun again. Ichthyol, in 5 to 10 per 
cent, strength in aqueous solution, has been highly ex- 
tolled by Unna and others, as well for external as for 
internal use. 

If the case is highly inflammatory when first seen, our 
first attempts should be in the direction of reducing the 
inflammation by means of soothing ointments. After a 
few days we can begin the treatment of the rosacea. 

Surgical procedures are necessary to hasten the removal 
of pustules, and to destroy dilated vessels and hyper- 
trophic tissue. Pustules are quickest removed by the cu- 
rette, as in acne. Dilated vessels are best destroyed by 
electrolysis with the electric needle attached to the nega- 
tive pole, introducing it perpendicularly into the vessel at 
one or more points of its course, and letting it remain for 
a few seconds until the vessel appears as a white line. 
The method of using electrolysis is more fully described 

iProg. Med., 1880, viii, 182, 



ROSACEA. 485 

under hypertrichosis. It is often necessary to repeat the 
operation several times before the vessel is destroyed. 
The thermo-cautery may also be used in the same way. 
Multiple scarification is most useful in reducing red 
patches! It may be done by means of a scalpel, making 
parallel lines near together and through the skin, and 
then a second series over these ; or a multiple scarifying- 
knife, as sold in the shops, may be used for the purpose. 
H. Fonrnier l advises the use of a flat needle rounded at 
its end and bevelled on its under side. The vessels are 
to be cut obliquely to their long axis, while the skin is 
put on the stretch. After scarifying, bleeding should be 
encouraged for a few moments by the application of hot 
water. Then the surface should be swabbed over with a 
solution of carbolic acid, two drachms to the ounce of 
glycerin and water. This will check the bleeding and 
constringe the vessels. No after-treatment is needed, as 
a rule. If reaction tends to go too far, a soothing oint- 
ment may be applied. The operation should be repeated 
once every week or two. It is astonishing to see how 
rapidly the redness will be reduced in many cases, and 
this without deformity being caused. Multiple scarifica- 
tions may be employed for the reduction of tuberculated 
masses, rhinophyma, but a plastic operation is the most 
satisfactory method of treatment. 

Pjrogxosis. In cases of rosacea arising from exposure 
to weather in drivers and sailors, and those following 
similar pursuits, we cannot expect to effect a cure, as the 
patients cannot do the one thing necessary — give up their 
occupations. In most all other cases we can promise 
great amelioration of the annoying redness, and in many 
we can effect a cure ; but we had best not attempt to 
treat a patient who will not follow our directions as to 
diet and hygiene. 

Rose. See Erysipelas. 

Rosee. See Rosacea. 

x Jour. mal. cutan., etc., 1895, vii., 257 



486 DISEASES OF THE SKIN. 

Rose Rash. See Erythema. 

Roseola. See Erythema roseola. 

Roseola Pityriaca. See Pityriasis rosea. 

Roseola Syphilitica. See Macular syphilide. 

Roseole Squameuse. See Pityriasis rosea. 

Rotheln (RuV-e^n), Rubeola, or German measles, is a 
mild contagious disease that resembles measles, but differs 
from it in the mildness of all its symptoms, in the lighter 
color and smaller size of its lesions, and in the absence of 
the crescentic arrangements of them. Its period of incu- 
bation is two to three weeks. Like measles, it may be 
mistaken for either an erythema or an erythematous 
syphilide, and its diagnosis is along the same lines as is 
that of measles, which see. It is not so blotchy as measles, 
and the catarrhal symptoms are absent or but slight. 
Swelling of the glands of the neck is a symptom that may 
or may not be present, but when present is characteristic. 
Febrile movement is slight. The lesions may take the 
form of small papules, and assume rather a brownish than 
a red color. The eruption is often itchy, and the lesions 
may occur on the mucous membranes. It differs from 
scarlatina in the mildness of all its symptoms, and in the 
absence of the diffuse scarlet eruption of the latter disease. 

Rothlauf. See Erysipelas. 

Rotz. See Equinia. 

Rupia. See Syphilis. 

St. Anthony's Fire. See Erysipelas. 

Salt-rheum. See Eczema. 

Salzfluss. See Eczema. 

Sarcocele of the Egyptians. See Elephantiasis. 

Sarcoma (Sa 3 rk-o'-ma 3 ). We are here interested in sar- 
coma of the skin alone. Sarcomas may be primary in the 
skin, but most often they are secondary. They form 



SARCOMA. 487 

Variously sized tumors, but tend to run a malignant 
course, multiplying more or less rapidly, breaking down, 
affecting internal organs by metastasis, and killing the 
patient in a few months or years. There are three types 
of sacoma — namely, the round-cell sarcoma, the small -cell 
sarcoma, and the melano or pigment sarcoma. Very 
commonly sarcomata are of mixed type ; or sarcomata 
may be divided into two varieties — the pigmented and the 
non-pigmented. 

According to Brocq, 1 who, following Perrin, has made 
an exhaustive study of the disease, primary melanotic sar- 
coma originates frequently from an irritated nsevus, or 
other pigmented lesion, but may occur independently. At 
first, it is always single and small. It tends to enlarge 
and attain the size of a nut. In shape it is oval or spher- 
ical. It is nearly always sessile. Its color is dark-blue 
or black. It is very hard to the touch. It may remain 
stationary for a long time, but in course of time new 
tumors will appear, either about the original one or at 
distant points by means of the lymphatics. Some of 
the original tumors will disappear, while new ones ap- 
pear ; some will break down and form irregular ulcers 
whose floors are black and uneven, and secrete a thick, 
melanotic liquid, or a little pus, or almost solid black mat- 
ter. A large lobulated mass may be formed by the co- 
alescence of a number of smaller lesions. The viscera 
become involved, and death soon occurs. 

A rare form of melanotic sarcoma is described by Hutch- 
inson as melanotic whitlow, which at first is a chronic ony- 
chitis, the border of which looks like a lunar-caustic stain. 
It very gradually develops into a fungating tumor, slightly 
pigmented. The nail is shed, and generalization occurs 
(Crocker). 

No n -pigmented primary sarcoma may be generalized or 
localized. The generalized form begins usually upon the 
extremities, and causes upon the hands and feet a peculiar 
hard oedema, accompanied by tension of the skin, and per- 

1 These de Paris, I889. 



488 DISEASES OF THE SKIN. 

liaps itching or pricking. It may begin as brownish-red, 
livid, purple, or blue patches, upon which little pinhead- 
size nodules appear, which gradually enlarge. In some 
cases little, infiltrated, isolated, blue or reddish-brown 
nodes will form. Sometimes the first appearance will be 
a diffused cyanotic patch, which later will become a bossy 
elevated patch. When the disease is fully developed the 
hands and feet are thick, deformed, infiltrated, as firm as 
cartilage, brown or blue with a red tint. The skin is 
glossy, scaly, uneven. The nodes may be raised, pedun- 
culated, or ulcerated. Similar lesions are found upon the 
rest of the body, though rarely on the trunk. They may 
remain stationary, disappear, fall off, multiply, ulcerate, 
or, finally, involve the mucous membranes, and cause 
death. 

The localized form develops ordinarily from an irri- 
tated nsevus, and is most often encountered on the ex- 
tremities. It forms a hard, wrinkled tumor, which may 
ulcerate. Its color is usually that of the normal skin, 
though it may be red. It may grow to be the size of an 
orange or take on a mushroom-like form. It may not 
generalize for a long time, or it may do so spontaneously, 
or after an attempt at removal. 

Sarcomas are very vascular, and are subject to profuse 
hemorrhage when injured or when they ulcerate. 

Under the name of idiopathic multiple pigmented sarcoma 
a disease was first described by Kaposi. It occurs in 
adults and begins as an oedema of the hands, feet, and 
face with more or less pruritus. Later dark blue or 
purplish spots appear deep in the skin, which after a time 
form raised nodules, which may be sessile or pedunculated, 
but are always dark blue or purple. The extremities or 
face become elephantiasic in appearance, and covered with 
scales and more or less rugous. The tumors may remain 
for a long time or disappear, or, rarely, ulcerate. The 
color of the tumors is due to vascular development. The 
disease is chronic in its course, and may last for fifteen or 
twenty years without affecting the patient's health. The 



SARCOMA. 489 

disease may extend up the limbs to the trunk. Recovery 
may take place. 

Etiology. We know very little in regard to the eti- 
ology of sarcoma. It occurs at all ages, some of the most 
malignant cases being seen in childhood. Brocq says that 
the localized non-pigmented sarcoma is most frequent in 
women, and that the generalized form is most frequent in 
robust men of forty to sixty years. Piffard gives the 
ages at which they are most prone to occur as before the 
fifteenth and after the forty-fifth year. 

Diagnosis. The diagnosis of sarcoma is generally 
easy, but at times it is difficult. The pigmented forms 
are usually readily recognizable by their color. The 
non-pigmented single sarcoma may be distinguished from 
epithelioma by its feel, which, though firm, lacks that stony 
hardness that is characteristic of cancer. Fibromata are 
not so firm as are sarcomata, are more commonly pedun- 
culated, and show no tendency to degenerative changes. 
Jlyeosis fungoides has a primary eczematous stage ; its 
tumors are of a brighter red and they come and go, and 
undergo various changes much more rapidly than do sar- 
comata. 

Treatment. Excision of a single non-pigmented sar- 
coma is often curative. In multiple sarcomata, and in the 
melanotic variety, operative interference is usually not 
only not curative, but has often seemed to hasten general- 
ization. Kobner and others have used hypodermatic in- 
jections of arsenic with brilliant results in some cases. 
Kobner used Fowler's solution of half strength, and in- 
jected two and a-half to four drops of it once a day. 
After three months the dose was increased to seven and 
a-half, and then to nine drops. Others have tried arsenic 
without effecting a cure. Still it is worthy of trial, as it 
may cure the disease if it is well borne by the patient. 
Inoculation by the toxin of the streptococcus has cured 
some cases, but its use is not without danger to the life 
of the patient. 

Prognosis. This is always grave. The course of the 



490 DISEASES OF THE SKltf. 

disease is nearly always from bad to worse, though the 
fatal result may not be reached for many years. Mela- 
notic sarcoma is more rapidly fatal than is the ordinary 
form. 

Satyriasis. See Lepra. 

Scabies (Skab'-i 2 -ez). Synonyms: The Itch; (Fr.) 
Gale ; (Ger.) Kratze. A contagious disease of the skin 
due to its invasion by the acarus scabiei and characterized 
by excessive itching, worse at night, and by excoriated 
lesions, pustules, and cuniculi upon the anterior face of 
the wrists, between the fingers, on the breast of women, 
the penis of males, and about the umbilicus of both sexes. 

Symptoms. The popular name of scabies, which is the 
Itch, gives us at once one of the marked features of the 
disease. Itching is always present in it. While it may 
be somewhat in abeyance during the day, it is hardly ever 
absent, and at night in bed it is so bad, in susceptible in- 
dividuals, that sleep is well-nigh impossible. The itching 
gives rise to scratching, and the scratching to the secondary 
symptoms of the disease — scratched papules and eczema- 
tous patches. 

The first thing that the patient notices is that his skin 
itches. To relieve this he scratches, and sooner or later, 
according to the resistance of his skin, he produces pin- 
head-size excoriations. Later, the irritation continuing, 
eczematous patches result. When he presents himself to 
the physician, the latter will find on examination excoria- 
tions due to scratching, and he will notice that the lesions 
are located principally between the fingers, on the anterior 
surface of the wrists and somewhat on the forearms, about 
the axillae, upon the breasts about the nipples in women, 
upon the male genital organs, about the umbilicus and 
lower part of the abdomen, and often upon the buttocks 
of both sexes, and, in children especially, upon the an- 
terior surface of the ankles and between the toes. In 
adults, these latter situations are not so frequently affected. 
Closer examination may be rewarded by the discovery of 



SCABIES. 491 

the pathognomonic sign of scabies — namely, the euniculus, 
or burrow, which is usually found most readily on the 
inner border of the hand, on the inside of the fingers, and 
on the penis. It forms a delicate, slightly raised, whitish 
or grayish, wavy, often bowed line, about one-eighth to 
one-half an inch in length, and having a white speck at 
one end which marks the place where the itch-mite is. 
These are not always to be found ; indeed, in most cases 
they are difficult to find, because they are broken up either 
by the occupation of the individual, by the use of soap 
and water, or by scratching. In people with delicate 
skin the burrowing of the itch-mite will set up an inflam- 
matory process, and papules, vesicles, and pustules will 
form, quite independently of the scratching. 

AVhile the regions mentioned are the ones always affected 
in well-marked cases, variations in the extent of the dis- 
ease are observable. In some cases the hands are free, 
and but few lesions are present anywhere. Here, if it is 
a male, the crucial test will be the examination of the 
privates, where a scratch-mark or a burrow will be found 
almost without fail. In other cases, hardly any part of 
the body will be free from excoriations, pustules, or 
eczematous patches, excepting the face, which is affected 
only exceptionally, and then nearly always in children. 
In these bad cases furuncles and large ecthymatous 
pustules join themselves to the already multiform eruption 
of scabies. Urticaria is also present in some cases, its 
wheals being interspersed among the other lesions. Should 
some intercurrent fever arise, the symptoms of scabies 
will subside, to reappear when the fever is past. The so- 
called Norwegian Itch is only a very much aggravated 
form of the disease, on account of the want of personal 
cleanliness of the people. The face in this form may be 
affected, the nails split and shed, and the palms and soles 
covered with thick crusts. 

Etiology. Scabies is due to the irritation set up by 
the acarus scabiei and by the scratching employed to re- 
lieve the same. The vesicles, papules, or pustules about 



492 DISEASES OF THE SKIN. 

the burrows are due directly to the acarus ; it may be on 
accouut of some irritating substance secreted by it. The 
disease is contagious, but requires prolonged contact, as 
by holding of hands, or sleeping with an infected person. 
It is very rare for it to be communicated to a physician in 
examining a patient. 

According to Greenough, 1 it is most prevalent between 
the ages of five and thirty, and comparatively rare after 
the fiftieth year. This, he thinks, is due to the fact that 
in advanced life the epidermis becomes harder and dryer, 
and forms a less suitable habitat for the acarus. A few 
years ago the disease was not common in this country, 
but now it is an every-day occurrence to meet with new 
cases in our dispensaries, and not an infrequent one to 
meet with it in private practice. 

Pathology. The acarus scabiei is very small, being 
barely visible to the naked eye, the female being but one- 
sixtieth to one-eightieth of an inch long, and the male 
still smaller. Its width is about two-thirds of its length. 
It has eight legs — four on each side of its head, to which 
suckers are attached, and four posteriorly, to all of which, 
in the female, bristles are attached ; while in the male the 
inner ones are wanting in bristles, but provided with suck- 
ers for attaching himself to the female in copulation. On 
the back are a number of short bristles. A glance at the 
accompanying plates will describe the animal better than 
words. 

The female acarus having landed on the skin, soon stirs 
about, and having found a suitable place, it rests on its 
hind feet, takes an oblique position, pierces the skin, and 
bores a hole, into which it forces itself. It lodges in the 
deeper layers of the epidermis, above, and sometimes in 
the mucous layer. It bores a burrow equidistant between 
the surface of the epidermis and the level of the papillae 
of the corium. Being prevented by the bristles on her 
back from moving backward, she moves forward, and lays 
her eggs. Her duration of life is from six weeks to two 

1 Boston Med. and Surg. Jour., Sept. 23, 1886. 



SCABIES. 



493 



months, and during this time she lays some fifty eggs. 
These hatch out, reach the surface of the skin, meet the 
male, become impregnated, bore in their turn into the 
skin, and so keep up the process. As the thinnest parts 
of the skin are most easily punctured, it is just in these 
parts that we find the lesions most commonly. The 
scratching often extends far beyond the sites of the bur- 

Fig. 58. 




Acarus scabiei. Back. 

rows. Fournier found that an acarus died in seven days 
when immersed in cold water, in ten days when in warm 
water, and in two to four days in a solution of green soap. 
He denies the commonly accepted view that the acarus is 
a night -prowler, though he allows that it is most active at 
night. 

Diagnosis. The presence of pustules and scratch- 
marks between the fingers, on the anterior face of the 



494 



DISEASES OF THE SKIN. 



wrists, about the umbilicus, on the breasts in women or 
the genitals in men, is enough to make the diagnosis of 
scabies. If a cuniculus can be found, it will be corrobo- 
rative evidence. Eczema is more patchy and does not 
occur in the characteristic locations of scabies. Pediculo- 
sis vestimentorum presents long, parallel scratch-marks in- 
stead of the small excoriations of scabies, and their char- 

Fig. 59. 




Acarus scabiei. Under surface. 



acteristic locations are over the shoulders, about the girdle, 
and along the outside of the arms and the inside of the 
thighs where the seams of the clothing come. The itch- 
ing of scabies is worst at night, while that of pediculosis 
is most marked in the daytime. Urticaria is a general 
disease characterized by wheals and shows no tendency to 
localize itself in certain regions. Should urticaria com- 
plicate scabies, the wheals will be disseminated while the 



SCABIES. 



495 



lesions of scabies will be most marked in their character- 
istic locations. 

Treatment. If the disease is recognized, there is no 
difficulty in curing it, though there are various methods 




Burrow of scabies with acarus. (After Kaposi.) 



employed. Perhaps the oldest and one of the most reli- 
able, though not the most rapid "cure," is to have the 
patient take a warm bath with soap and water, scrubbing 



496 DISEASES OF THE SKIN. 

himself thoroughly so as to remove as much of the old 
epidermis as possible. Then he should dry the skin with 
vigorous friction, and rub into every diseased spot ordi- 
nary sulphur ointment. When this is done he can smear 
the rest of the skin with the ointment, put on the same 
clothes, and go about his business. The rubbings with 
the ointment are to be repeated morning and night for 
three days, the patient wearing the same underclothing by 
day, and bed- and night- clothing by night. At the end 
of three days another bath is to be taken, the clothing 
changed, and the patient should then present himself for 
examination. If fresh lesions are found, a second course 
should be taken, which most always will be sufficient. 
An artificial eczema is apt to be set up by the sulphur, 
and as eczema itself itches we must not take the continu- 
ance of pruritus beyond the second course as evidence of 
the scabies not being cured. It is better to stop the sul- 
phur for a few days, and put the patient upon a mild, 
protective dressing to his skin, such as vaseline and corn- 
starch. If the itching grows worse instead of better, a 
third course of rubbing must be gone through with. In- 
stead of plain sulphur ointment we can add balsam of 
Peru, about half a drachm to the ounce, or use the modi- 
fied Wilkinson's ointment, as follows : 



Cretse preparat, 3y ,ss 5 10 



Xt ' } aa 3j ; p - e - ad 10 ° 



M. 



This, though a very efficient remedy, forms such a dis- 
gusting-looking mass and is so irritating that it is fit only 
for public practice. /9-naphthol, in 5 to 10 per cent, 
strength in ointment or oil, is a good remedy, free from 
the sulphur smell, and not so irritating. Kaposi recom- 
mends it in the following form ; 



SCABIES. 497 

E. /?-naphthol, 15 parts. 

Sapo. viridis, 50 " 

Cretse alb. pulv., 10 " 

Adipis, 100 " M. 

and Crocker says : "I can speak of it in the highest 
praise/' It is well fitted for private practice. McCall 
Anderson extols styrax liquida with a double amount of 
lard. As the itch is very prevalent in Scotland, the doc- 
tor should know of what he speaks. Too free use of this 
remedy may cause a nephritis, so patients using it must be 
watched. 

The treatment in the St. Louis Hospital of Paris is a 
heroic one, but is said to cure in one hour and a-half. 
According to Fournier, the patient is scrubbed violently 
for half an hour with green soap ; then for another half- 
hour the scrubbing is continued while he is in a bath ; 
then he is rubbed with this ointment : 

Helmerich's Ointment. 



B • Potass, carbonat. , 
Sulphur, sublimat. 
Adipis, 



S ss ; 


15 


BJ; 


30 


Siv; 


120 



M. 



Now he puts on his clothes without removing the salve, 
and is discharged cured. In private practice Founder 
recommends the use of a good toilet soap for the prelim- 
inary rubbings, and then Bourguignon's ointment as fol- 
lows : 

R. Glycerini, 200 parts. 

Gum. tragacanth. , 5 " 

Sulph. sublimat., 100 " 

Potass, carb, 35 " 

01. lavandulse, ] 

01. menth pip, [■ -- L50 « M 

01. caryophylh, 
01. cinnamomi, J 

This is to be followed by a bath and powdering with 
cornstarch. It cannot be used for children, or in exten- 
sive cases in adults where there is much excoriation. 

For infants and young children, balsam of Peru is 
32 



498 DISEASES OF THE SKIN. 

about the pleasantest application we can make, it being 
rubbed in morning and night, either pure or diluted with 
sweet oil ; or a mitigate form of sulphur ointment may 
be used. 

Sherwell l commends rubbing in dry powdered sulphur 
after a bath, and dusting a little in between the sheets so 
that the patient sleeps in an atmosphere of sulphur. 

In all cases the clothing and beddiug must be disin- 
fected — washable things by boiling, and cloth clothing by 
baking or by ironing with a very hot iron. All affected 
members of the family must be treated at the same time. 
An irritable condition of the cutaneous nerves sometimes 
lasts long after the scabies is cured, and must not be mis- 
taken for a still active itch. 

Prognosis. The prognosis is always good, provided 
the applications are made thoroughly enough. 

Scall or Scalled Head. See Favus. 

Scarlatina (Ska 3 r-la 3 -ti r -na 3 ). Scarlet fever is an acute 
contagious eruptive disease with an incubation period of 
one day to two or three weeks, with an average of eight 
days. It is characterized by a quick rise of temperature 
at the beginning, redness of the fauces, a strawberry 
tongue, and the appearance of a fine punctate scarlet 
rash, which, first appearing on the neck, chest, and flex- 
ures of the joints, rapidly spreads over the whole body. 
The redness may be even over all, so as to give a boiled- 
lobster appearance to the skin ; or the red points may be 
distinct, although close together. The redness usually 
disappears on pressure. Vesicles may appear. A great 
deal of constitutional disturbance and prostration are apt 
to attend the eruption, but convalescence is well estab- 
lished in the second week in uncomplicated cases. Abun- 
dant desquamation follows the subsidence of the eruption, 
which continues for days or weeks. 

Diagnosis. There is often a striking resemblance be- 

1 N. Y. Med. Journ., 1893, i., 432. 



SCLEREMA NEONATORUM. 499 

tween scarlatina and erythema scarlatinifornie, and some 
other erythemata. (See Erythema.) 

Scherende Flechte. See Trichophytosis capitis. 

Schmeerfluss. See Seborrhoea. 

Schuppenflechte. See Psoriasis. 

Scissura Pilorum. See Atrophia pilorum propria. 

Sclerema. See Scleroderma. 

Sclerema Neonatorum (Skle 2 r-e r -ma 3 ). Synonyms : 
Scleroderma neonatorum ; Induratio tela? cellulosse ; (Fr.) 
Algidite progressive, I/endurcissement athrepsique ; (Ger.) 
Das Sclerem der Neugeboren. 

This happily rare disease was first differentiated from 
oedema neonatorum, according to Crocker, by Parrot, in 
1877. It may be primary, but most often it is secondary 
to some exhausting disease, such as pneumonia or intesti- 
nal catarrh. It may be present at birth, and rarely oc- 
curs after the first ten days of life. It is characterized 
by hardness of the skin, which generally at first is cir- 
cumscribed and affects the leg. It may be diffused from 
the first, or it soon becomes so, and extends to the lumbar 
regions, back, chest, and so all over the body, becoming 
universal by the fourth day. It may begin on the face, 
and it may stop before becoming universal. It may be 
but slightly developed on the chest. At first the skin is 
pale and waxy ; later, it becomes livid and cold, and the 
child looks as if frozen. The skin becomes attached to 
the underlying parts, smooth, tense, and does not pit on 
pressure. Movement is impossible for the child, and the 
body may be raised without bending a joint. When the 
face is affected it is impossible for the child to nurse. Its 
respirations are greatly reduced in number, its pulse falls 
to sixty per minute, its temperature is below normal, its 
breath is cool, and it dies within a week. The primary 
congenital cases are either stillborn or die in one or two 
days. Localized cases sometimes recover, the hardness of 
the skin disappearing. 



500 DISEASES OF THE SKIN. 

Etiology. The cause of the disease is obscure. It is 
seen almost exclusively in foundling-asylums and among 
the very poor. It is, therefore, a disease of depressed 
vitality. Langer l regards it as the result of solidifica- 
tion of the fat, which in infants contains 31 per cent, of 
palmatin and stearin, that of adults containing 10 per 
cent. The fat in infants, he says, is nearly all concen- 
trated in the subcutaneous tissues, where it is five times 
as thick relatively as it is in adults. Naturally, an in- 
fant's temperature is higher than an adult's, and, if it is 
lowered by any depressing cause, the fat may solidify. 
Solidification may take place also under the action of cold, 
or by oxidation, as in fevers, withdrawing some of the 
constituents of the fat. Parrot regards the disease as one 
of desiccation from the drain of a diarrhoea, or the like. 

Diagnosis. Sclerema neonatorum is differentiated 
from oedema neonatorum by being more general in its dis- 
tribution, by the skin being harder and more tense, and 
not pitting on pressure, and by the rigidity of the joints. 
Scleroderma occurs at a later age than does sclerema, and 
the skin lacks the coldness of the latter. There are no 
other diseases with which sclerema can be confounded. 

Treatment. The course of the disease is almost in- 
evitably toward a fatal termination, and little more can 
be done than to keep the little body as warm as possible, 
to rub in oil, and to administer concentrated nourishment 
and stimulants. Money 2 reported a case in 1889 that 
was cured in six weeks by mercurial inunctions. There 
was no history of syphilis in the case. 

Scleriasis. See Scleroderma. 

Sclerodactylie. See Scleroderma. 

Scleroderma (Skle^-o-du^rm'-a 3 ). Synonyms : Sclerema 
seu Scleroma adultorum ; Scleriasis ; Dermato-sclerosis ; 
Ohorionitis ; Sclerostenosis ; (Fr.) Sclereme des adultes, 
Sclerodermic ; (Ger.) Hautsclereme ; Hide-bound disease. 

1 Wien. med. Presse, 1881, xxii., 1375. 
Lancet, 1889, i., 526. 



SCLERODERMA. 501 

A subacute or chronic disease, characterized by hard- 
ness and rigidity of the skin. 

Symptoms. The name of this disease indicates the most 
peculiar feature of it — that is, hardness of the skin. It 
may come on without apparent cause, the patient first 
noticing the stiffness of the skin ; or it may follow expo- 
sure to dampness and cold, and be preceded by pains of 
rheumatic nature. It may begin in any part of the skin, 
but has a preference for the upper half of the body. It 
is usually symmetrical, though it may be more pronounced 
on one side than on the other. Having begun, it spreads, 
it may be very slowly, or it may be so rapidly as soon to 
involve large areas of the body. It often runs a capricious 
course, growing better and worse, and leaving sound areas 
in the midst of the diseased parts. There may be one 
patch or a number of them, and the patches assume many 
shapes, though most commonly they are elongated, run- 
ning lengthwise of the limb. There are two varieties of 
the disease : 1. The infiltrating form. In this there is a 
good deal of infiltration of the skin, which is hard, cannot 
be pinched up, does not pit on pressure, and is attached 
to the deeper structures. The appearance given to the 
affected part is cadaveric. In some cases there may be 
hard oedema. The affected part is usually on the level of 
the surrounding parts, though it may be slightly raised. 
The infiltration merges gradually into the neighboring 
parts, its border being ill-defined and more readily felt 
than seen. The natural folds of the skin are obliterated, 
erythema may be present at first, and telangiectases are 
frequently observed upon the surface. Not infrequently 
the patch has a lilac border. The color of the skin is 
paler than that of the normal integument, and in some 
places it may be that of ivory. Some scaling may be 
present, or pigmentation of a mottled or diffused character 
may give the patch a fawn to black color. Owing to the 
stiffness of the skin, the movement of the joints is inter- 
fered with, a state of pseudo-ankylosis being established. 
If the face is affected, it loses its expression, and the fea- 



502 DISEASES OF THE SKIN. 

tures become immobile. The eyelids may escape for some 
time ; but if the disease passes on to the atrophic stage, 
soon to be mentioned, the eyes become wide open and 
cannot be closed. If the chest is much affected, respira- 
tion is interfered with. The temperature of the skin is 
usually lowered one or two degrees. It may be normal, 
or somewhat elevated. Sensibility may be increased, 
normal, or decreased. Pruritus is at times annoying. The 
secretions of the skin are lessened with the increase of the 
disease. 

The disease may invade all the mucous membranes. 

2. To this form the second or atrophic form may succeed 
after months or years. Crocker thinks that it is probable 
that atrophy follows the oedematous infiltration only. 
When atrophy begins it is progressive, and the skin be- 
comes dry, wrinkled, parchment-like. It is most often 
the upper part of the body that is affected — the face and 
arms. Continuous contraction of the skin produces an 
atrophy of the muscles under it, so that finally nothing 
remains of the original structures but the skin and bones, 
and the joints are ankylosed. The face being affected, we 
will find a corpse-like expression, wide-open eyes with 
ulcerated corneas, shrunken gums with loosened and fall- 
ing teeth. The limbs being affected, slight injuries will 
produce ulcerations over bony prominences, and the limbs 
will be semiflexed. The sclerodadylie of Ball is sclero- 
derma of the atrophic variety, affecting the hand and 
causing marked atrophy, loosening the joints, and distort- 
ing the hands, " so that the third and fourth fingers are 
curled up into the hand, the first and second are bent at 
the first phalangeal joint, while the thumb phalanges are 
overdistended." (Crocker.) 

The general health remains unaffected, often for years ; 
but should the disease be very pronounced, at last a 
marasmic condition develops and death occurs. Apart 
from the pruritus and feeling of stiffness, we may have no 
subjective sensation, excepting that pain on pressure is 
exquisite. At times burning is complained of. The dis- 



SCLERODERMA. 503 

ease, when of the infiltrated variety, tends to a slow and 
interrupted course toward recovery. In the atrophic 
variety recovery may take place. Of course, the atrophied 
skin will never regain its natural texture, but the disease 
may cease to spread and increase. At best, its subject is 
but a sorry specimen. 

Children may have scleroderma, the youngest reported 
case beiD^ thirteen months. In them the disease is said 
to run a more rapid course, both in development and re- 
covery, than it does in the adult. Vidal 1 describes a 
form of scleroderma following a lesion of the skin, such as 
an eczema, which gives rise to a lymphangitis, and is 
usually met with on the leg. 

Etiology. Women are far more often the victims of 
scleroderma than are men — three to one. It is most com- 
mon in young and middle-aged adults. Apart from this, 
we are in uncertainty as to the true cause, though rheu- 
matism, gout, exposure to cold and heat, bad hygiene and 
poor food, and neurotic influences have each been found 
in apparent causative relation to the disease. At the 
foundation of the trouble there is supposed to be some de- 
fect in the nervous system, not improbably in the vaso- 
motor center. 

Diagnosis. There is no other disease of the skin with 
which scleroderma could well be confounded, excepting 
sclerema or oedema neonatorum, morphoea, or cancer en 
euirasse. The age at which the first two occur — namely, 
the first few days of life — would throw them out. 3Ior- 
phcea is a localized scleroderma, and the diagnosis is there- 
fore unimportant. Cancer en euirasse is more rapidly fatal 
in its course, is at first or soon marked by subcutaneous 
nodnles that tend to break down and ulcerate, and is ac- 
companied by lancinating pain. 

Tkeatmext. It is doubtful if treatment is ever di- 
rectly of avail. At best, it is unsatisfactory. A general 
symptomatic treatment with tonics, good diet, and main- 
tenance of the body heat is indicated. Galvanism, in- 

li. ; 939. 



504 DISEASES OF THE SKIN. 

unctions of the skin with oil, and massage may be tried. 
West 1 has reported amelioration in one case by the ex- 
ternal use of chaulmoogra and olive oil. Graham 2 ad- 
vises the use of anti-rheumatic remedies. Hyde has 
obtained benefit by the use of salt, either moistening it 
with warm water until it is partially dissolved, and then 
rubbing it briskly over the entire surface of the body ex- 
cepting the face, and then washing it off with water of 
decreasing temperature until cold water is used, or a warm 
tub or sponge bath is taken containing one-quarter of a 
pound of salt to the gallon. I have seen one case im- 
proved by inunctions of vaseline containing 10 per cent, 
of salicylic acid. 

Peognosis. While recovery may take place, it is un- 
certain as to its occurrence. Death may result. In 
children the prognosis is more favorable. 

Scleroderma Neonatorum. See Sclerema neonatorum. 

Scleroma Adult orum. See Scleroderma. 

Sclerostenosis. See Scleroderma. 

Scrofulide Boutoneuse Benigne. See Prurigo. 

Scrofulide Crustacee TJlcereuse. See Tuberculosis cutis. 

Scrofulide Erythemateuse. See Lupus erythematosus. 

Scrofulide Tuberculeuse. See Lupus vulgaris. 

Scrofuloderma (Skro 2 f-u 2 l-o-clu 5 rm'-a 3 ). Modern pathol- 
ogy has led, or is leading, us to use the term tubercular 
as synonymous with scrofula, and a number of dermatoses 
that were for many years regarded as scrofulodermata have 
been proven to be due to the bacillus tuberculosis. The 
most brilliant example of this is lupus vulgaris. Many 
of the scrofulides of the French have been shown by more 
careful observation to belong to various other well-recog- 
nized forms of skin disease. The marks of a scrofulous 
affection are, according to Bazin : (1) The involvement 

1 Trans. Path. Soc. Lond., 1883, xvi., 252. 
2 Journ. Cutan. and Gen.-Urin. Dis., 1886, iv., 332. 



SCROFULODERMA . 505 

of the deeper layers of the skin ; (2) the sharply circum- 
scribed character of the lesions ; (3) the absence of pain ; 

(4) hypertrophy followed by atrophy of the affected parts ; 

(5) the reddish violaceous or livid color of the lesions ; 
and (6) indelible cicatrices left by the same. 

In the present condition of our knowledge of the sub- 
ject, and in a book of this sort, it is impossible to clo more 
than to place here a few affections of the skin that do not 
fit in under other well-established diseases, while premis- 
ing our remarks by saying that they are either really in- 
stances of cutaneous tuberculosis, or will eventually be 
taken out of their present position as scrofulodermata. In 
all of them we have, at the same time, that general make- 
up of the individual that long has been recognized as 
scrofulous. The patients are mostly young subjects, flabby 
of flesh, with pasty or doughy complexions, thick upper 
lips, perhaps with clubbed fingers, a marked tendency to 
chronic catarrhal inflammations of all the mucous mem- 
branes, chains of enlarged glands in the neck, and per- 
haps with some old or present bone lesions. They are 
usually dull and apathetic, and are prone to die with 
tubercular lung diseases. 

The most common scrofuloderm is that resulting from 
a suppurating caseous gland, usually of the neck — the 
scrofulous ulcer. The gland, before it breaks down, im- 
plicates the skin over it, and it becomes of violaceous or 
livid color, attached to the underlying parts. By and by 
the skin gives way at one or several points ; the sanious, 
unhealthy pus escapes through the openings ; these en- 
large, coalesce with others, and so form the characteristic 
ulcer. This has undermined edges ; is of irregular shape ; 
its base is covered with flabby granulations ; it discharges 
a thin, sanious pus ; shows little tendency to crusting ; is 
almost painless, and heals very slowly, leaving a puckered, 
disfiguring scar that is often bridled. Only one gland 
may be affected or there may be a number of them that 
enlarge and break down. This same form of ulcer may 
originate from what is called a scrofulous gumma, a sub- 



506 DISEASES OF THE SKIN. 

cutaneous tubercle independent of the glands, that slowly 
enlarges to a soft tumor, breaks down, and ulcerates. 
These tumors frequently occur on the limbs, and the bones 
may be involved in the destructive processes set up. 

While this is the most common scrofuloderm, we occa- 
sionally meet with two forms described by Duhring — the 
large and the small pustular scrofuloderm. The former has 
" large, rounded, ovalish, or irregularly shaped, yellow- 
ish, flat pustules, with a deep red or violaceous areola." 
This begins to crust in the center, and the crust is usually 
flat and scanty, brownish and adherent. Underneath it is 
an ulcer with the characters and course of those just de- 
scribed. There may be one, two, or more lesions. The 
small pustular scrofuloderm " consists in the formation 
of pinheacl- and small split-pea-sized, disseminated, yel- 
lowish, flat pustules, with usually a raised, violaceous 
areola." These crust over with depressed yellowish or 
gray adherent crusts, which when removed, or when 
they fall off, leave depressed, punched-out scars resem- 
bling variola. Their course is very chronic and painless. 
They occur upon the face and extremities of strumous in- 
dividuals. 

Etiology. The causes of these scrofulodermata are 
those of the strumous state, pus infection by the tubercle 
bacillus, and need not be gone into here. They are most 
commonly met with in early life. 

Diagnosis. The scrofulous ulcer differs from that of 
lupus vulgaris by an entire absence of the characteristic 
lupus tubercles,, and by its history of beginning in a 
caseous gland. Moreover, in lupus we do not have, as 
a rule, the pronounced strumous condition that we have 
in the scrofuloderm. The pustular scrofuloderms some- 
times resemble syphilis, but there is an absence of other 
signs of syphilis, and the presence of the strumous state. 
Moreover, the pustular syphilide is generally far more 
disseminated than is the scrofuloderm ; its course is far 
more acute, it yields more readily to treatment, and leaves 
a smoother, less disfiguring scar. 



SEBACEOUS CYST. 507 

Treatment. The treatment of the ulcers, as well as 
the softening glands, is upon surgical principles. The 
regulation of the diet and hygiene of the patient, and the 
administration of cod-liver oil, iron, the compound syrup 
of the hypophosphites, or other tonic, is the most essential 
part of the medicinal treatment. Locally, to the pustular 
scrofuloderms we may apply iodoform ointment, aristol, or 
other antiseptic powder, or mercurial ointments or lotions. 
Crocker speaks well of chaulmoogra oil emulsion in the 
dose of ten to thirty minims, combined with its external 
use as an ointment in the strength of one part to three. 

Scrofuloderma Verrucosum. See Tuberculosis verrucosa 
cutis. 

Scurvy. See Purpura. 

Sebaceous Cyst. Svnonvms : Atheroma ; Steatoma ; 
Wen. 

These innocuous little tumors may occur anywhere on 
the body, but are most common on the scalp, face, neck, 
and back. They vary in size from a millet-seed to an 
orange. They may be rounded, flattened, or hemispher- 
ical. There will be found in many of them a small open- 
ing, out of which some of their contents may be pressed. 
The skin over them may be of normal color, pale on ac- 
count of pressure, or red if the cyst becomes inflamed. 
They may be elastic and doughy to the touch, or firm, or 
soft, according to the condition of their contents, which 
may be fluid and honey-like, or cheesy. They tend to 
grow slowly, and give no trouble except by the deformity 
they cause. In exceptional cases they may become in- 
flamed and ulcerate. The hair is usually absent over 
them when they occur on the scalp. Cysts of similar 
nature may be found in locations where there are no 
sebaceous glands, and even under the mucous membranes. 
These are called dermoid cysts, and are supposed to be left 
over from foetal life. They frequently contain hair and 
teeth. 



508 DISEASES OF THE SKIN. 

Etiology. Most cysts are due to distention of a seba- 
ceous gland. They occur in both sexes in adult life, be- 
ing rare in children. The origin of dermoid cysts is 
undetermined. Indeed, considerable uncertainty sur- 
rounds the pathology of all of them. 

Fig. 61. 





Sebaceous cysts of scalp. (Hyde. ) 

Diagnosis. They must be distinguished from fatty 
tumors and gummata. Fatty tumors are firmer and more 
doughy than cysts, and are more often lobulated, occur but 
seldom on the scalp, and are rarely multiple. Gummata 
are more rapid in their growth, attached to the skin, and 
tend to break down and ulcerate. 

Treatment. Complete excision of the tumor, taking 
particular care to remove the whole sac, is the only treat- 
ment to be considered. 

Seborrhagia. See Seborrhoea. 

Seborrhcea (Se 2 b-o 2 r-re'-a 3 ). Synonyms : Stearrhoea, 
Steatorrhea, Seborrhagia, Fluxus sebaceus, Acne sebacea. 



SEBORRHCEA. 509 

Pityriasis, Ichthyosis sebacea, Tinea amiantacea sen asbes- 
tina, Eczema seborrhoiciun, Lichen circinatns ; (Fr.) 
Acne sebacee, Acne" fluente ; (Ger.) Schmeerfluss, Gneis ; 
(Ital.) Seborrea. 

A functional disorder of the sebaceous glands, in which 
there is a hypersecretion of sebaceous matter, which may 
be of too fluid or too solid consistence, and forms either 
an oily coating or greasy crusts on the skin. 

Symptoms. Normally the sebaceous glands secrete 
only sufficient oil to keep the skin soft and supple. This 
normal oil is not visible to the naked eye. Under certain 
imperfectly understood conditions, the glands secrete a too 
fluid and abundant oil that is readily seen as an oleaginous 
coating of the skin. This form of seborrhoea is called 
seborrhoea oleosa and it is now held to be the only form of 
seborrhoea. By many it is thought that under certain 
other equally imperfectly understood conditions, the secre- 
tion of these glands is not only too abundant, but also too 
consistent. Then the sebaceous matter cakes upon the 
skin in the form of more or less thick plates or masses, 
and to this condition the name of seborrhoea sicca is given. 
The latter form is now regarded as seborrhoeal dermatitis 
or eczema. 

The most common locations of seborrhoea are, naturally, 
those regions where the sebaceous glands are the largest 
or most numerous, namely : the scalp, the chest, the in- 
terscapular region, and the face. 

Seborrhoea oleosa, while it may occupy any or all of these 
regions, is usually subjected to us for treatment only when 
it occurs upon the face. Here it is seen most often on the 
nose, where it forms a greasy coating. At times this is so 
slight as to be felt rather than seen, imparting a slippery 
sensation to the finger. At other times it is so abundant 
that it can be seen at a distance as drops or beads of oil, 
and when it is removed with a cloth or blotting-paper it 
leaves an oily stain upon it. When it is wiped off it at 
once reforms. As the greasy skin catches the dust the 
face is apt to look dirty. At times the skin of the nose 



510 DISEASES OF THE SKIN. 

may be hyperseniic. The forehead is, likewise, a not un- 
common site for this form of seborrhoea. It may occur 
on the scalp, and render the hair unusually oily. It is 
most often noticed when the patient is bald. It is apt to 
cause alopecia. Upon the nose it may occur as the only 
disease of the skin. Upon the forehead and nose it is not 
an unusual accompaniment of acne. Acne and comedones 
may complicate the disease in any location. 

Seborrhoea sicca occurs with much greater frequency 
than does the oily form of the disease. We are called 
upon to remove it from all the regions already mentioned 
as the locations for the manifestations of seborrhoea. It 
most usually appears in the form of yellowish or grayish 
fatty plates or masses, which when taken and rubbed be- 
tween the fingers impart a greasy feel. Upon the scalp it 
constitutes one form of dandruff. Here it may be general, 
involving the whole scalp, or it may locate itself in cer- 
tain places in a more pronounced way than in others. Or it 
may take the form of rings. The hair is dry, and after a 
time, the seborrhoea continuing, it begins to fall, and at 
last baldness is established. 

In this form of seborrhoea the hairy regions are espe- 
cially affected, and we find it in the eyebrows, bearded 
portions of the face, and the hairy portions of the chest. 
The axillae and pubes are rarely affected. In all these 
places it presents similar appearances, yellowish or gray- 
ish fatty plates. Upon the chest it is not uncommon to 
see the fatty matter in little heaps, piled up as it were 
about the mouths of the hair follicles. Close observation 
will show that the follicle mouths are wider open than 
they should be. As in the oily form, the skin feels greasy, 
and acne and comedones may be present. The interscap- 
ular region is frequently affected, and both here and on 
the chest the disease often takes the form of round or 
irregularly shaped patches which look as if they were 
covered with a brownish-yellow varnish. This is the 
seborrhoea corporis of Duhring and the lichen circinatus 
of the older English authors. 



SEBORRHEA. 511 

Aside from the appearance of the fatty crusts and a 
slight amount of itching when the patient is warm, this 
form gives rise to no symptoms. When the crusts are 
removed the underlying skin is of normal appearance. It 
may be slightly paler than it should be, but it is never 
moist. What the patient complains most about is that 
the scales from the crusts, becoming loosened, fall upon 
the clothing and make it look as if powdered. If the 
patient happens to be bald, he does not find the yellow- 
ish fatty crusts upon his bald head at all ornamental. 
But the most serious aspect of the case is that if the 
disease is not cured it is very sure to cause the hair to 
fall, especially if the patient is at all predisposed to bald- 
ness. 

There is a second variety of seborrhoea sicca, in which 
a varying amount of dermatitis is added to the seborrhoea. 
Then there will be a rim of redness about the fatty crust, 
and when the crust is removed from the skin the under- 
lying part will be seen to be red. In this variety there 
will be far more decided itching; and burning than in the 
preceding variety. It is to be noted that although the 
skin is red, it is always dry and never infiltrated, in these 
respects differing from eczema. 

Upon the nose this variety of seborrheal dermatitis 
forms a yellow plate with a red line about it. At times 
this plate may be extensive enough to cover the whole 
nose. More frequently the disease is limited to the fur- 
rows behind the alee nasi, and then assumes the form of 
some fatty scales upon a good deal of underlying redness. 
The eyebrows and bearded portions of the face are also 
quite commonly affected, but rather as a diffuse redness 
combined with a branny scaling, than as a solid plate sur- 
rounded by a red line. 

Besides the regions already mentioned as the usual loca- 
tions of seborrhoea, we also meet with the disease upon the 
ears (in the tragus and behind the ears), and in the anal 
fold. The scalp is, however, by far the most frequent 
location of the disease, and here it may exist alone for 



512 DISEASES OF THE SKIN. 

years. Whenever it exists elsewhere, it is sure to be 
found at the same time upon the head. 

In infants the disease is very common, taking the form 
of thick crusts upon the scalp, that are often of a dirty- 
gray color. These give the careful mother a good deal of 
annoyance, she being in great dread lest someone should 
think that she is not careful to keep the precious baby 
clean. This form of the disease is usually the remains of 
the vernix caseosa. 

Etiology. The usual etiological factors of seborrhoea, 
as given in the text-books, are debility, chlorosis, consti- 
pation, and a number of other things, indicating that the 
condition of the patient is below par. Of course, the abil- 
ity of these to cause seborrhoea is questioned ; but that 
they are quite capable of aggravating the disease I have 
no doubt. The disease affects all classes and conditions 
of men, all ages, and both sexes. 

There are many things that seem to indicate a con- 
tagious element in the etiology of the disease. Cases have 
been reported in which a husband or wife has contracted 
dandruff after marriage, he or she having been, before, free 
from the same. The experiments of Lassar and Bishop 
point in the same direction. They took the scales from 
the head of a student who was losing his hair, and, having 
made a pomade of them with vaseline, rubbed the same 
into the back of a guinea-pig, and the pig became bald. 
Up to two years ago we accepted without question the 
theory that seborrhoea was a functional disease of the seba- 
ceous glands. It is now thought that there is no such dis- 
ease as seborrhoea. Unna teaches that the process is in- 
flammatory from the start, and that the oil that fills the 
epithelial scales comes not from the sebaceous glands, but 
from the sweat glands. What we have called seborrhoea 
sicca he would have us call, for the present at least, sebor- 
rheal eczema. (See Eczema seborrhoicum.) He also re- 
gards it as parasitic. 

In support of his thesis he presents us with microscop- 
ical studies and certain arguments. His work has been 



SEBORRHCEA. 513 

reviewed by oilier competent pathologists, and his obser- 
vations have been substantiated by their findings. His 
proposition that the sebaceous glands are not responsible 
for seborrhea has not been accepted generally. 

What we call seborrhoea oleosa, Unna believes to be 
nothing more than a hyperidrosis, to which he gives the 
name of hyperidrosis oleosa. This view he must take of 
necessity, on account of his theory of the office of the 
sweat glands. 

It is affirmed that seborrhoea is due to a micro-organ- 
ism. Brooke, of Manchester, believes that, to the para- 
site of seborrhoea without dermatitis, another parasite 
adds itself, to produce the dermatitis and the ring forma- 
tion. For further information the reader is referred to 
the article on eczema seborrhoicum. 

Diagnosis. The diagnosis of seborrhoea sicca is usu- 
ally easy. It is to be recognized by the presence of fatty 
grayish or yellowish plates or crusts, seated either upon a 
normal or slightly reddened skin. These crusts or plates 
differ from those met with in eczema, in being more read- 
ily removed, and imparting to the finger a greasy feel. 
Moreover, the crusts of eczema are of a more solid con- 
sistence, being formed by the drying of an almost muci- 
laginous discharge upon the skin. When eczema occurs 
upon the head the exudation glues the hairs together. 
In seborrhoea the hairs are not glued together, but are 
dry and powdery. In eczema there is more or less 
itching at all times, while in seborrhoea the itching comes 
on most generally when the head is hot, as from artificial 
lights, sweating, and the like. In eczema there is mois- 
ture, or a strong tendency thereto. In seborrhoea moisture 
is never seen. 

Psoriasis is another disease with which seborrhoea sicca 
is apt to be confoundeol, as it, too, occurs in the form of 
powdery scales and crusts upon the scalp. If a case pre- 
sents itself with these conditions upon the head alone, you 
may be very sure that you have to do with a case of seb- 
orrhoea, as psoriasis rarely exists upon that region alone. 
33 



514 DISEASES OF THE SKIN. 

Seborrhoea usually occurs diffusely, while psoriasis occurs 
in the form of circumscribed patches. The crusts of seb- 
orrhoea are yellowish or grayish, while those of psoriasis 
are of a silvery hue. In some cases, however, seborrhoea 
will occur in circumscribed patches, and the crusts of 
psoriasis may be of a grayish hue. 

When seborrhoea sicca occurs upon the chest and back 
in the form of rings with scaly centers, we have before us 
a more difficult problem in diagnosis. Now we must de- 
cide whether we have to do with a seborrhoea, a ringworm, 
or a pityriasis rosea. The resemblance to ringworm is 
often very striking, but ringworm does not, as a rule, oc- 
cur in so diffuse a manner. If, at the same time with the 
lesion on the chest, we find other lesions on the back be- 
tween the shoulder-blades, we may be quite sure that the 
case is one of seborrhoea. Happily in any doubtful case 
we have a sure resort in the microscope. If the case be 
one of ringworm, we will surely find the trichophyton. 
Upon examining the scalp, if the disease be seborrhoea, 
we will surely find plain evidence of it there. There 
should be no difficulty in recognizing the presence of a 
ringworm on the scalp. 

In the differential diagnosis from pityriasis rosea, we 
are deprived of the kindly aid of the microscope. Here, 
too, the occurrence of seborrhoea on the scalp will aid us 
in our decision. Moreover, pityriasis rosea is generally 
more diffused over the trunk than is seborrhoea, and oc- 
curs also on the arms and abdomen. By close inspection 
we may trace the development of the disease from its be- 
ginning as a small red spot through its successive growth 
into the typical oval to annular patch with its withered 
parchment or chamois leather-like looking center. It is 
scaly, never crusted. In some cases, however, the diagno- 
sis will remain somewhat doubtful. 

Treatment. The treatment of seborrhoea is simple. 
It is somewhat in favor of the parasitic theory of the ori- 
gin of the disease that the drugs that are most efficacious 
in its cure are active antiparasitics. In my hands by far 



SEBOERBCEA. 515 

the most satisfactory remedy has been sulphur. After 
the removal of the crusts by means of any oil or grease 
(this should be done the first thing whates^er remedy is 
chosen) 3 the sulphur is to be applied in the strength of a 
drachm to the ounce, either suspended in sweet oil, cotton- 
seed oil, or vaseline. It should be well rubbed into the 
scalp, and the application repeated every night for one 
week. It must be remembered that the remedy is to be 
applied to the scalp and not to the hair, and that it is nec- 
essary to use only a very little of the ointment. After 
one week's use of the sulphur the head is to be washed 
with soap and water, and the oil, or salve, immediately re- 
applied. During the second week it will be sufficient to 
make the application every other night. Thus the treat- 
ment is to be continued, the number of applications being 
reduced until they are made but once a week. By this 
time the disease will usually be cured. The patient is to 
be cautioned that relapses are likely to occur, and there- 
fore it will be best for him to keep a supply of his oil, or 
salve, on hand so as to attack the trouble as soon as it 
shows itself. 

The objections to sulphur are two : it has a slight 
odor, and it leaves a slight yellow powder on the 
scalp. The first objection is of not much importance 
and may be overcome by the addition of a scent. The 
second is lessened by cautioning the patient not to use 
the application too freely, and by having him wash the 
head. 

The ointment recommended by my distinguished friend, 
Dr. Bronson, is a very elegant as well as efficient substi- 
tute for the sulphur. It is 

R. Hydrarg. ammon., 9jij; 5-101 

Hydrarg. chlor. mitis, 3ij-iv; 10-20 

Vaselini, gj; 100 M. 

This is be used in the same manner as the sulphur 
ointment. 

While one or the other of these will bring the case to a 



516 DISEASES OF THE SKIN. 

happy issue, it is well to have a variety of means at com- 
mand. H. E. Crocker l recommends : 

R. 



Ac. acetici, 

Resorcin. , 

Aq. cologniensis, 


5J; 


15-30 
4 
60 


Glycerini, 
Aquse rosse, 


, oh.. 

ad gviij; 


4 
250 



M. 

Some other remedies are salicylic acid in castor oil, three 
per cent, strength ; resorcin in oil, diluted alcohol, or vas- 
eline in three to ten per cent, strength ; or a solution of 
hydrate of chloral, a drachm to the ounce ; while for a 
soap, both for cleansing and stimulation nothing is better 
than the tincture of green soap. If the scalp is pecul- 
iarly irritable then it is best to use a milder soap, such 
as Pear's glycerine soap. 

The treatment of seborrhoea of the body and face is 
upon the same lines as that of the scalp, only that on the 
body we can use an ointment instead of an oil. 

For the seborrhoea of infants usually all that is required 
is to keep the scalp well oiled with olive oil. If this does 
not cure, then a mild sulphur ointment with vaseline may 
be used. 

For seborrhoea oleosa dabbing ether on the part will 
most promptly remove the greasy look. Washing with 
soap and water will act as a stimulant. Powdering with 
sulphur and starch, or using a three per cent, solution of 
resorcin in alcohol and water, will tend to cure. 

In all forms general treatment will be called for if the 
patient is out of tone. General tonic treatment is required 
in nearly all cases of seborrhoea oleosa. 

Under Alopecia furfuracea wil! be found further direc- 
tions as to the treatment of seborrhoea of the scalp when 
it has led on to baldness. See also Eczema seborrhoicum, 
which is that I have here described as seborrhoea sicca, 
in deference to the older teachings. 

Seborrhoea Congestiva. See Lupus erythematosus. 
1 Clin. Jour. Lond., 1897, x., p. 81. 



SUMMER ERUPTION. 517 

Shingles. See Zoster. 

Siderosis (Si 2 d-e 2 r-o'-si 2 s). A defacement of the skin 
due to the entrance into it of small particles of iron or 
steel, producing blue-black marks. It is seen in iron- 
workers. 

Sommersprosse. See Lentigo. 

Spargosis. See Elephantiasis. 

Spedalskhed. See Lepra. 

Sphaceloderma. See Dermatitis gangrenosa. 

Spider Cancer. See Telangiectasis. 

Spitzes Condylom. See Verruca and Syphilis. 

Stearrhoea. See Seborrhoea. 

Steatoma. See Sebaceous cyst. 

Steatorrhcea. See Seborrhoea. 

Stigmasie. See Hsematidrosis. 

Stigmata. See Hsematidrosis. 

Stinkschweiss. See Bromidrosis. 

Stonepock. See Acne. 

Striae et Maculae Atrophicae. See Atrophoderma stria- 
tum et maculatum. 

Strophulus. See Miliaria. 

Strophulus Albidus. See Milium. 

Strophulus Prurigineux (Hardy). See Prurigo. 

Sudamina. See Miliaria. 

Sudatoria. See Hyperidrosis. 

Sudor Urinosus. See Uridrosis. 

Sueurs Colorees. See Chromidrosis. 

Summer Eruption of Hutchinson. Sec Hydroa vaccini- 
forme. 



518 DISEASES OF THE SKIN. 

Sweating", Excessive. See Hyperidrosis. 

Sycosis (Sik-o'-si 2 s). Synonyms : Sycosis non parasitica ; 
Sycosis menti ; Sycosis barbae ; Mentagra ; Acne mentagra ; 
Folliculitis barbae; Folliculitis pilorum; Herpes pustulosis 
mentagra; Lichen menti ; Acne sycosis ; (Fr.) Sycosis non 
parasitaire ; Dartre pustuleuse mentagre ; Adeuotrichie ; 
(Ger.) Bartfinne, Bartflechte; Fikosis; (Eng.) Barber's itch. 

Definition. An acute or chronic follicular and peri- 
follicular inflammation of the long hairs, chiefly affecting 
the bearded portions of the face ; characterized by an 
eruption of papules, pustules, and tubercles perforated by 
hairs ; by the formation of infiltrated patches ; and by a 
greater or less amount of crusting. Sometimes the dis- 
ease is so intense as to form abscesses. 

Symptoms. It is only of comparatively recent years 
that this disease has been recognized as a separate entity, 
and it is still regarded by some authorities as merely a 
form of eczema. The disease begins by the formation of 
a number of red inflammatory papules and tubercles which 
are more or less conical, usually raised above the surface 
of the skin, and always perforated by hairs. Their ap- 
pearance is preceded and accompanied by disagreeable 
local sensations, such as pricking, burning, and smarting, 
and at times by a feeling of tension in the part on account 
of swelling of the skin. In acute cases there is consider- 
able redness of the skin between the papules, and the in- 
flammation may be so intense as to give rise to enlarge- 
ment of the neighboring lymphatic glands. The papules 
and tubercles vary in size from that of a millet seed to 
that of a pea, and are isolated or grouped, not every hair 
follicle in a diseased part being affected by the perifollicu- 
lar inflammation. Only in very severe outbreaks or in 
acute exacerbations do the papules and tubercles tend to 
run together and form infiltrated patches. 

The papules and tubercles soon change into pustules, 
which preserve the same characteristics of grouping and 
are likewise always pierced by hairs. These pustules, 
conical in shape, and perforated by hairs, are pathogno- 



SYCOSIS. 519 

nioiiic of the disease. In old cases they are met with in 
the infiltrated patches arising apparently without the pre- 
ceding appearance of papules and tubercles. The pustules 
show no tendency to rupture, but the pus accumulates be- 
low, swells up alongside of the hair, appears upon the 
surface of the skin, and dries into thin crusts. The 
amount of crusting is never very great, far less than in 
eczema of the beard, and is appreciable mainly when the 
beard is growing. If the inflammation is very intense, we 
may meet with small cutaneous abscesses here and there 
instead of pustules. According to A. E. Robinson, the 
amount of pus-production varies with the individual at- 
tacked, being more rapid and abundant in the robust than 
in the scrofulous ; in acute than in chronic cases. 

The hairs, if of any length, are early affected in appear- 
ance, becoming lustreless. They are at first firmly seated 
in their follicles, and when pulled upon give rise to pain, 
and if extracted their root sheaths will appear as clear 
glassy cylinders. Later, as pus forms more abundantly 
in the peri-follicular tissues, and the follicles themselves 
are involved in the process, the hair becomes loosened 
and easily extracted, when its root sheath will be found 
swollen with pus. If the pus-production is excessive, the 
hairs will fall of themselves or upon the slightest traction. 
"When this occurs the hair papillae may be so damaged 
that no new hairs will form. In chronic cases the beard 
is markedly thinned, though permanent loss of hair is the 
exception. 

The disease may attack any part of the bearded face, 
and may be met with in other hairy regions, as the neck, 
the eyebrows, scalp, axilla, and pubes. But the beard is 
by far most often the site of the disease, the other situa- 
tions being affected in the order in which thev are named. 
Occurring in the beard it may be limited to a single region 
and show no tendency to spread. Thus it is met with 
very frequently upon the upper lip alone, or at times 
upon the chin alone. It may attack the whole bearded 
face in an acute outbreak, or it may involve it by exten- 



520 DISEASES OF THE SKIN. 

sion from a limited area during a number of successive 
outbreaks. In chronic cases it is usually symmetrical. 
The course of the disease is chronic and made up of a 
number of acute exacerbations. If left to itself, it may 
produce a good deal of deformity, the tubercles and pus- 
tules breaking down, ulcerating and leaving cicatricial tis- 
sue and more or less baldness, though this is exceptional. 

A typical case of sycosis presents the following appear- 
ance : upon a single region, two or more regions, or upon 
the whole bearded portion of the face there mil appear 
a number of isolated or grouped papules, tubercles, and pus- 
tules pierced by hairs. The skin about the lesions is red- 
dened and swollen, it may be indurated, and there is a 
slight amount of crusting. There is no tendency for the 
disease to spread to non-hairy parts, but very commonly 
the eyebrows will be similarly affected, and a blepharitis 
will be present. When the case is watched for a time 
marked exacerbations will arise often without apparent 
cause, last for a few days, and then the disease will sink 
into a subacute condition. When the disease affects the 
vibrissa? of the nose, by extension from the upper lip, the 
Schneiderian membrane becomes swollen and exquisitely 
sensitive. The disease tends to run a chronic course, 
lasting for years. 

Etiology. The etiology of the disease is not settled. 
It is not very common, perhaps one case in three or four 
hundred. It is doubtless contagious in some cases and 
transferred by the agency of the barber shop. It is seen 
in men almost exclusively, as we might expect, as it is 
the beard that is most often affected ; and attacks them 
most frequently between the ages of twenty-five and 
fifty. It affects all classes and conditions. Most of its 
subjects are in poor general condition. 

Eczema is often a forerunner of sycosis, the one pro- 
cess passing over into the other. A nasal catarrh is the 
cause of the majority of cases occurring on the upper lip. 
Shaving with a dull razor against a stiff beard is some- 
times an exciting cause, though those who do not shave 



SYCOSIS. 521 

are by no means exempt from the disease. An irritant 
applied to the skin may excite it, such as exposure to in- 
tense heat, the dust of a workshop, cosmetics, and the 
like. Exposure to inclement weather is regarded by 
Wilson as the principal cause. One of the worst cases I 
have ever met with was directly traceable to a poultice 
applied to the face for the relief of a neuralgia, Given 
a hypersemic or irritable condition of the skin of the face, 
arising from any internal or external cause, the hairs, 
especially if they are coarse, may excite the disease, act- 
ing as irritants when touched or moved. 

Hebra thinks that some cases may be due to an abnor- 
mality in the growth of new hairs. Wertheim ascribed 
the inflammation to irritation of the hair follicle by hairs 
whose diameter was, relatively, too large for their follicles. 
The staphylococcus pyogenes is found in relation with 
most cases of sycosis, but this would prove inoperative 
unless the soil was in proper condition for its growth. 
Tommasoli has found a bacillus in some cases. 

Pathology. The disease is primarily a peri-follicu- 
litis, the hair follicles being affected secondarily, and after 
them the sebaceous glands. 

Diagnosis. The distinguishing characteristic of syco- 
sis is the presence of pustules pierced by hairs. It must 
be diagnosed from trichophytosis barbae, eczema barbae, 
the small pustular syphiloderm, acne, and lupus. The 
differential diagnosis of sycosis from trichophytosis barbae 
is as follows : 

Trichophytosis Barbje. Sycosis. 

Begins as a small scaly spot, a superficial Begins suddenly •with an outbreak of 
ringworm, and gradually involves the papules which soon become pustules, 

deeper parts of the hair. each of which at the start involves a 

hair, 
lias its favorite seat upon the chin and Its favorite seat is the upper lip, and 
the submaxillary region ; rarely sometimes it alone is involved. In- 

attacks the upper lip. volves the hairy portions of the face 

more generally, and is often sym- 
metrica]. 
The eruption consists of tubercles and The eruption consists of papules and 
nodules which tend to group, and arc pustules, each of which is pierced by 

studded with a number of hairs. The a single hair, and they show no dis- 

internodular portions of the skin often position to -roup. The intervening 

remain unaffected, skin is generally reddened, and mar 

be diff'usedly infiltrated ; and ab- 
scesses' may form. 



522 



DISEASES OF THE SKIN. 



Trichophytosis Babble. 

Is a deep inflammatory process so soon 
as the hairs hecome affected. 

Hair is diseased primarily, and is 
twisted, split, and broken. May 
readily be removed by slight traction 
and without pain. Its root is often 
dry. 

Subjective symptoms slight, may be 
only slight pruritus. 



Patches of ringworm often present on 
other parts of the body, and some- 
times the disease extends upon the 
neck or face. 

Hairs and scales loaded with the tri- 
chophyton fungus. 

Is a progressive disease, and when 
cured not liable to relapse. 



Sycosis. 
Is a more superficial inflammation. 

Hair diseased secondarily, and comes 
away at first with difficulty, causing 
much pain. Later is easily removed 
and its root is swollen with pus. 

Subjective symptoms of pricking, burn- 
ing, and teusiou of the part. These 
are often intense and attended by 
swelling of the face. 

Limited in most cases to hairy parts of 
face. No tendency to extend on non- 
hairy parts of face or neck. 

No fungus present. 

The course of the disease made up of a 
number of acute outbreaks. Liable to 
relapse. 



The differential diagnosis from eczema of the beard can- 
not be made with so much certainty, and often we must 
remain for a while in doubt as to the true nature of the 
case. At times sycosis is left by a preceding eczema, and 
we may meet with a case in the transition-stage when a 
sure diagnosis would, manifestly, be impossible. A typical 
case of pustular eczema is attended by a far greater amount 
of crusting than is sycosis, and the crust is of a more 
greenish or blackish color. Upon removing the crust in 
eczema a moist and oozing surface will be exposed, while 
in sycosis we will do no more than remove the tops from 
a number of pustules. In eczema the pustules break 
down more readily than in sycosis, and they are not so 
accurately located about the hairs. In eczema the whole 
surface of the skin is involved, and the process tends to 
extend upon non-hairy parts of the face. While excep- 
tionally eczema is confined to the hairy portion of the face, 
this is always so in sycosis. The duration of the disease 
will at times help us to a diagnosis, sycosis being far more 
chronic than is eczema. In syphilis, when the beard is 
involved, we will find pustules upon other portions of the 
body, and the history will help us to a correct conclusion. 
Further, the pustules or papules of syphilis are grouped 
in circles and segments of circles, are of a peculiar color, 
and their development is painless and comparatively slow. 



SYCOSIS. 523 

Acne is scattered about the whole face, and is usually met 
with in young persons. Comedones are present, and its 
papules, pustules, or tubercles have no definite relation to 
the hair. The course and history of lupus are so different 
from those of sycosis that it is hardly possible for them to 
be confused. In lupus vulgaris we have the characteristic 
brown tubercles, which do not contain pus, are not con- 
fined to the hairy portions of the face, generally begin in 
early life, and tend to ulcerate or to be absorbed and leave 
behind cicatrices. 

Treatment. The treatment of sycosis is both general 
and local. While many cases will yield to local treatment 
alone, there are quite as many, if not more, which require 
general treatment. The surroundings of the patient must 
be inquired into, and his mode of life, and we should en- 
deavor to put him in as good a hygienic condition as pos- 
sible. He should be advised against exposing himself to 
dust and wind, and then only with his face powdered or 
protected with ointment, and even against smoking, espe- 
cially in a wind where the smoke blows against the face. 
The proper regulation of the diet is important. Many 
cases will improve if we stop their tea, coffee, hot drinks 
of all sorts, ale, beer, and spirits. If the digestive pro- 
cess seems at all embarrassed, it is well to put the patient 
on a light diet for morning and evening, and direct him 
to take his principal meal at noon, eating meat only at 
that time. Anything that is known to him to be indi- 
gestible must, of course, be prohibited. In a word, the 
diet and hygiene of the patient should be regulated. 

What medicines we should administer will depend upon 
the stage of the disease. In the acute stage, when there 
are much swelling and inflammation, a good close of blue 
pill, calomel, or some other active cathartic is to be or- 
dered, to be followed by an alkaline diuretic. When pus- 
t illation is active the sulphide of calcium or calx sulphu- 
rata may do good. Piffard recommends this very highly, 
giving one-tenth of a grain two or three times a day. 

Small doses of calomel, of one-tenth of a grain, three 



524 DISEASES OF THE SKIN. 

times a day, for two or three days at a time, are useful in 
relieving the congestion of the skin. In chronic cases 
iron, cod-liver oil, and other tonics arc indicated if there 
is a state of debility. Arsenic is advised in very obsti- 
nate cases. If indigestion is present, we must address 
our remedies to its relief before we give calcium, arsenic, 
or other remedy for the disease proper, and then we will 
probably have no need of so-called specifics. 

The local treatment must vary with the condition found, 
whether it be acute or subacute, and is more important 
than the general treatment. When the disease attacks 
the upper lip the nose must be examined for evidences of 
catarrh, and that condition treated if found. 

In the management of an acute case of sycosis soothing 
remedies are needed. Hot water should be sopped on the 
part for some five or ten minutes once or twice a day, and 
this should be followed, if the beard is growing, by the 
use of a simple oil, such as olive oil or sweet almond oil ; 
or if the face is shaved, the zinc oxide ointment or cold 
cream may be used ; or better still, Lassar's paste, as 
follows : 



Zinci oxidi, J a O J > 

Vaselini, ad §j ; 32 



M. 



Powdering the part with cornstarch, or bismuth and 
talc, after smearing on a little vaseline, will at times give 
ease and comfort. 

In the early stage, if the inflammatory symptoms are 
not very inteuse, a mild white precipitate ointment will 
sometimes check the disease. Duhring recommends bath- 
ing the face with " black wash," followed by zinc oxide 
ointment with a drachm of alcohol or half a drachm of 
camphor to the ounce, spread on cloths and bound on ; 
and speaks well of the oxide of zinc ointment with fifteen 
to thirty grains of calomel to the ounce. 

When the disease has reached the pustular stage, and 
there is more or less crusting, the crusts are to be removed 



SYCOSIS. 525 

by the free use of olive oil, or oil of sweet almonds with 
two per cent, of salicylic acid, letting it soak in thor- 
oughly over night and washing the part with soap and 
warm water the next morning. If the crusts are thick, 
it a good plan to tie up the bearded face in a towel after 
anointing it with oil. After the crusts are gotten rid of, 
the hairs should be pulled out of the pustules and epila- 
tion continued until pustules cease to form. The patient 
must be made to understand that epilation is necessary 
both for the cure of the aifection and the salvation of the 
hair. After epilating, the oxide of zinc ointment, Lassar's 
paste, or diachylon ointment is to be used. Shaving is 
recommended, but it seems to me better to content our- 
selves with cutting the hair short. Shaving is apt to 
irritate the skin, and certainly would favor the dissemina- 
tion of the pus organisms. Sulphur in the form of an 
ointment, half a drachm to a drachm to the ounce, or in 
powder, will sometimes do good, but often will prove too 
irritating. Tilbury Fox recommends the use of the fol- 
lowing ointment after epilating : 



R . Zinci oxidi, 

Zinci carbonat. , 



5i ; 4 



Ungt. aq. rosae, ad §j ; 32; M. 

Instead of an ointment we may use oxide of zinc, one 
drachm to the ounce of linseed or other oil. Shoemaker 
advises the application of equal parts of oleate of mercury 
and olive oil. 

In subacute and chronic cases a more active treatment 
is necessary. Here our aim is not so much to allay in- 
flammation as to stimulate the skin. To this end we may 
use the soap and salve treatment of Hebra, which renders 
such good service in chronic cases of eczema. (See page 
201.) In some cases better results will be attained by 
the use of diachylon ointment, or Lassar's paste with ten 
or fifteen grains of salicylic acid to the ounce. In very 
obstinate cases where there is much thickening of the skin 
green soap may be kept applied to the part like an oint- 



526 DISEASES OP THE SRIK 

ment. When sufficient inflammatory reaction is produced 
emollient measures, as in the acute stage, should be used. 
Our success in treating these cases will vary with the 
thoroughness with which the dressings are applied. All 
ointments must be spread on cloths, not on the skin, and 
the dressings must be kept continuously in close contact 
with the affected part. Sometimes a sulphur ointment, 
one-half a drachm to two drachms to the ounce ; an oint- 
ment of iodide of sulphur ; the ointment of the ammoniate 
(gr. xv-xxx ad 3j) or the nitrate (5j-ij ad Sj), or the red 
oxide (gr. v-xv ad Sj) of mercury will prove useful. 
Robinson recommends the following ointment : 



R. Ungt. diachyli (Hebra), ) -- *. 
Ungt. zinci oxidi, j aa 5JSS ' 



50 



Ungt. hydrarg. ammon., 5"J I 10( 

Bismuth, subnitrat., 5J SS '■> 5 1 M. 

He has found cod-liver oil the best local application in 
strumous subjects. 

Behrend has obtained good results by scraping the af- 
fected parts with the dermal curette and dressing with a 
simple ointment or oil. All abscesses must be opened. In 
some cases the following ointment has given me satisfac- 
tion after other combinations have failed : 

R. Hydrarg. sulph. rubri, 

Sulph. sublimat, 12 

Adipis, ad 50 

01. bergamot, q. s. M. 

To be kept on constantly. 

Solutions of the bichloride of mercury, 1 in 1000 ; or of 
resorcin in alcohol 5 per cent, strength, after shaving, 
may be used. 

Kaposi recommends the following : 

R . /3-napthol. , 1 

Spt. sapo. viridis, 25 



Alcoholis, 50 

Bals. peruv., 2 

Sulph. loti, 10 



M. 



SYPHILIS. 527 

The ammonio-sulphate of ichthyol and other drugs used 
by eataphoresis are eonnnended. 

Boric acid, salicylic acid, and numerous other remedies 
seem to do good in some cases. To assure against a re- 
lapse it is necessary to continue making applications to the 
skin for four or five months after apparent recovery. 

Prognosis. This is one of the most obstinate of dis- 
eases. Left to itself, when once under headway it shows 
no tendency to get well, and has been known to last 
twenty or thirty years. Even under the most judicious 
treatment it is an obstinate disease, taking weeks or 
months before a cure is effected. Relapses are exceedingly 
liable to occur, and these sometimes show a disposition to 
recur at certain seasons. Unless the hair is carefully 
plucked from the inflamed follicles permanent baldness 
may be caused. But the disease is not dangerous to life, 
and it is curable. 

Sycosis Contagiosa. See Trichophytosis barbae. 

Sycosis Frambcesia. See Dermatitis papillaris capillitii. 

Sycosis Parasitica. See Trichophytosis barbae. 

Syphilis 1 (Si 2 f'-i 2 l-i 2 s). Synonyms: Malum venereum ; 
Lues ; Morbus Gallicus, seu Italicus, seu Hispanicus, seu 
Xeapolitanus, seu Indicus ; (Fr.) Yerole, or Grosse verole ; 
(Ger.) Lustseuche ; (Eng.) Bad disorder, Pox. 

Whole books have been written upon this disease. 
Here we can give only a brief outline of the disease, and 
that as it affects the skin alone. For a further account 
of the disease the reader should consult the larger special 
treatises. 

Symptoms. Syphilis may be acquired or hereditary. 
It is acquired by local infection, the first manifestation of 

1 In the description of the syphilides I have followed very closely 
those given by Prof. G. H. Fox in his Photoc/raphic Illustrations of Skin 
Diseases, Treat, N. Y. ; and by Prof. E. W. Taylor in his Pathology and 
Treatment of Venereal Diseases", Lea Brothers & Co. , Philadelphia, 1895. 
To both of these gentlemen I would extend my grateful thanks for the 
permission to use their books that was so graciously granted to me. 



528 DISEASES OF THE SKIN. 

which is the appearance of the initial lesion, commonly 
called the chancre or hard sore. In probably ninety per 
cent, of the cases this initial lesion is located on the geni- 
tals, and in the vast majority of these its site in males is 
the glans and prepuce. But the initial lesion may be 
found on any part of the body, and within the mucous 
cavities. According to a table of one hundred and ninety- 
eight extra-genital lesions compiled by Pospelow, 1 the fe- 
male breasts were affected in sixty-nine cases ; the lips in 
forty-nine cases ; the throat in forty-six cases ; and then in 
very much less frequency the gums, tongue, chin, eyelids, 
nose, trunk, anus, arms, and legs. Some obscure cases of 
syphilis are due to the initial lesion being in the urethra 
or upon the cervix uteri or deep in the throat, and thus 
escaping detection. 

The initial lesion appears within two to six weeks after 
inoculation with the syphilitic poison ; usually the interval 
is less than four weeks ; exceptionally it may be ten weeks. 
This is the period of incubation. Opinions are divided 
as to whether the initial lesion is a purely localized lesion, 
or the expression of a general constitutional infection that 
first declares itself at the point of inoculation. It appears 
to me that the weight of the argument is altogether on 
the side of the last opinion. The initial lesion may as- 
sume the form of a scaly patch, a dry or moist papule, a 
superficial erosion, or a circumscribed ulcer with perpen- 
dicular edge. Induration of the base is a characteristic 
of all forms of initial lesion ; it is sharply defined and 
imparts to the fingers a distinct resistance that may be as 
firm as cartilage. Commonly it is parchment-like. To 
detect it, the lesion must be gently pinched between the 
thumb and finger. It is present coincidently with the 
appearance of the initial lesion or within a few days after- 
ward. It remains for a long time after the disappearance 
of the lesion — for two or three months or longer. The 
secretion from the initial lesion, when present, is thin and 
chiefly serous. The duration of the lesion is variable ; it 
iArcli. f. Derm. u. Sypli., 1889, xxl, 59. 



SYPHILIS. 529 

may disappear before the outbreak of cutaneous symptoms, 
but very often remains for some time after this eyent. 
Unless there has been ulceration, no cicatrix will be left. 
It may leaye a staining of the skin or an induration. It 
is usually a solitary lesion, though it may be multiple. 
Enlargement of the nearest lymphatic glands accompanies 
the initial lesion. If on the external genitals, it will be 
those of one or both groins. They become hard, and are 
painless and freely movable. Suppuration is rare, and 
probably the result of mixed infection. A pleiad of 
glands, three arranged in a triangle, is quite characteristic 
of syphilitic infection. In women initial lesions are often 
so small and last so short a time that they are not noticed. 
In them induration is often not noticeable, and the diag- 
nosis is much more difficult than in men. They are found 
on the externa] genitals, within the vagina, and on the 
cervix uteri. 

The initial lesion may at first assume the character of 
the soft sore. This is the result of mixed infection with 
both the virus of syphilis and the local venereal ulcer. 
The ulcer will after a while become indurated and assume 
its proper characteristics. It is in these cases that a sup- 
purating adenitis may develop. Modifications from loca- 
tion of the initial lesion must also be noted. 1. Of the 
urethra. These may be at the meatus, in the fossa navic- 
ulars, or deeper parts. Those at the meatus attract at- 
tention by causing a slight impediment to urination. The 
lips are found glued together by a scanty, viscid secretion. 
The normal opening of the urethra becomes lessened by 
the induration which usually involve.- the entire circum- 
ference of the meatus. Those deeper down may give rise 
not only to interference with urination, but also to some 
pain, and later to a muco-purulent or purulent discharge 
like that of gonorrhoea, because they cause a urethritis. 
They may be felt as a hard, tender, circumscribed nodule, 
and be seen, with the endoscope, as a grayish-red erosion 
of the urethral wall. They may give rise to symptoms of 
stricture. 2. Of the anus. These may be without the 



530 DISEASES OF THE SKIN. 

anus, at its margin, or within the anal ring, and usually 
present a thickened, fissured, ulcerated surface. They are 
of a pale rose tint, and decidedly indurated. 3. Of the 
fingers. 1 They may be seated at any part of the phalanges, 
but most often are at the sides or base of the nail, or at 
its free margin. They begin as a papule, pustule, excoria- 
tion, or fissure, and attract attention as an obstinate hang- 
nail or fissure, and we find an irregular, deep-red, some- 
what elevated mass that is ulcerated and covered with a 
scanty, serous secretion. The finger is apt to be swollen 
at its end. The epitrochlear and axillary ganglia are en- 
larged, and there may be moderate lymphangitis. 4. Of 
the lips. They are usually covered with a greenish-brown 
crust, which, when removed, leaves either an erosion of 
little, if any, hardness, or an ulceration of cartilaginous 
consistence. The lips may be greatly swollen. They 
may begin as a fissure or painful excoriation. The lips 
are nearly equally affected, but usually only one. The 
submaxillary glands on the side of the lesion are usually 
first affected. 5. Of the tongue. Here we meet with hard 
circumscribed, flat, slightly elevated, dull red, smooth, pea- 
size nodules ; or a round, sharply defined, fleshy red, 
raised, hard ulcer. The cervical and submaxillary glands 
are enlarged. 6. Of the throat. The patient first notices 
difficulty or pain in swallowing, the latter in the region 
of the tonsils. Then the submaxillary and cervical glands 
become swollen. Examination shows en intense, limited 
or diffused, general or unilateral, brown or dark redness 
of the pharynx. The tonsils are enlarged, hard, and red, 
and may be eroded, and perhaps covered with an ash- 
colored deposit, a false membrane. Or we may find an 
irregular, hard ulcer with gnawed-out edges, and, may be, 
crater-shaped floor covered with dirty-brown or grayish 
deposit. One or both tonsils may be affected. 7. Of the 
nipple. These are usually multiple, and may take the 
form of an erosion, a scaly patch, or an indurated fissure. 

1 An admirable study of these lesions by Dr. R. "W. Taylor will be 
found in the Medical Record, 1891, xxxix., 69. 



SYPHILIS. 531 

The size varies from that of a lentil up even to three 
inches in diameter. They are sometimes linear, some- 
times sickle-shaped along one side of the nipple, and 
sometimes completely encircle the nipple. The nipple is 
red, or dark red, enlarged, hardened, and at times flattened. 
Mastitis may complicate matters. The axillary glands 
are enlarged, as are often those along the upper edge of 
the pectoralis major. On healing, the initial lesion leaves 
a flattening of the nipple, and perhaps a leaning of it to 
one side, characteristics that should put us on our guard 
in the examination of wet nurses. 

About six weeks after the appearance of the initial lesion 
(it may be as early as the twenty-fifth day, or as late as 
the one hundred and sixtieth), we have the stage of erup- 
tion of the so-called secondary syphilides. Usually, just 
before the outbreak of the eruption, or shortly after it, 
examination will show a general enlargement of the lym- 
phatic glands, especially the epitrochlear and post-cervical. 
At the time of the eruption, or shortly before, the patient 
will experience certain constitutional disturbances such as 
severe headache, malaise, pains in the joints, and a rise of 
temperature of moderate extent. In very many cases 
these disturbances either do not exist, or are of so slight 
severity as not to attract the patient's notice. In some 
cases a more or less profound anaemia will manifest itself, 
or the patient will fall into a markedly cachectic condition. 
Either of these may last far into the secondary period of 
the disease. Weakly individuals are more prone to these 
severe constitutional derangements than are the robust, 
and Fournier teaches that they are most apt to appear in 
women. 

The eruptions of syphilis are, for convenience, divided 
into two groups named, respectively, secondary syphilides 
and tertiary syphilides ; or the early and late lesions. No 
hard and fast lines can be drawn, as sometimes those 
lesions usually seen late in the disease manifest themselves 
early in its course. The secondary syphilides are those 
that develop during the first two years after infection. 



532 DISEASES OF THE SKIN. 

They are marked by a more or less general and symmet- 
rical dissemination over the whole cutaneous surface ; by 
polymorphism ; by running a rather definite course ; by 
implicating the more superficial parts of the skin and 
mucous membranes ; and by leaving little, if any, trace of 
themselves. In these respects they differ from the lesions 
of late syphilis, which are grouped and limited to certain 
regions ; are not polymorphic ; show less tendency to run 
a definite course, involve the deeper structures, and are 
prone to leave permanent scars. 

The eruptions of secondary syphilis are the erythema- 
tous, the papular, and the pustular syphilide. The first 
eruption of the secondary stage is usually an erythema- 
tous one, the macular syphilide, or the syphilitic roseola. 
Unlike other syphilides, which are all largely composed 
of new cell-growth, this may be a hyperemia without 
cell-infiltration. It may be a general eruption, though 
generally most marked upon the trunk and flexor aspects 
of the limbs. The macules are about the size of a ten- 
cent piece, or smaller, of a faint rose-red color, circular in 
form, and little, if at all, raised above the skin. At 
times we meet with annular lesions from disappearance of 
the center of the macule. The lesions, excepting in re- 
lapsing eruptions, are distinct from each other. They 
become more evident on exposure to cold, it being no un- 
common thing to see them appear upon the patient's body 
while he is before us stripped for examination. After 
being out for a time their color becomes purplish-red, 
changing to a tawny or yellowish-red, and later to a 
brownish-yellow. In their early stage they can be made to 
disappear on pressure. They either disappear, and leave 
either no trace or some pigmentation, or they develop into 
papules. They often coexist with papules and pustules. 
Their evolution usually requires a week or ten days ; 
sometimes it may appear very rapidly. It runs a course 
of one to three months if not removed by treatment. 
Relapses occasionally occur, and these may be met with 
as late as the end of the first year. Then it is usually 



SYPHILIS. 533 

limited to certain regions. It gives rise to no inconven- 
ience, and is often overlooked by the patient except when 
it appears on the face or hands. At this time there is apt 
to be an erythematous condition of the pharynx, some 
sore-throat, a rheumatoid affection of the joints, falling of 
the hair, and, perhaps, an iritis, and mucous patches in 
the mouth, upon the vulva, in the groin, upon the scrotum 
and under surface of the penis, and about the anus. 

While the diagnosis is easy, if we have seen the patient 
from the time of the initial lesion, in some cases we must 
differentiate between it and mottling of the skin ; an ex- 
anthem ; a medicinal eruption ; chromophytosis ; and, if 
we have annular macules, trichophytosis corporis. From 
mottling of the skin it is diagnosed by the fact that in 
syphilis we have macules of a reddish tint, interspersed 
with skin of normal hue, while in mottling we have light 
macules with dull purplish-red interspaces. From an ex- 
anthematous fever it is diagnosed by the absence of catar- 
rhal or gastric symptoms, and marked pyrexia, and by the 
sluggish character of its lesions. From a medicinal erup- 
tion it is diagnosed by an absence of gastric disturbance, 
and by its lesions lacking the urticarial or oedematous 
character. From cJiromophytosis it differs in having a 
red rather than a cafe-au-lait color, by not being scaly nor 
capable of removal by scraping, by its more extensive dis- 
tribution, and by the absence of the microsporon furfur 
from the scales when they are examined under the micro- 
scope. From trichophytosis it differs in the greater extent 
of its distribution, and the absence of the trichophyton 
fungus from scales scraped from the skin. From pityri- 
asis rosea, the differentiation is sometimes difficult when 
the syphilitic macules have assumed a ring-form. As a 
rule, there is no difficulty, as a pityriasis rosea will be 
scaly, and will present not only rings, but macules of all 
sizes, while the syphilitic macules are not scaly, and are 
of more uniform size. 

The papular syphiUde, while usually following the ery- 
thematous syphilide, may be the first eruption of the dis- 



534 DISEASES OF THE SKIN. 

ease. Indeed a great many cases begin as a maculo-papu- 
lar eruption. The papules may develop from macules, or 
may appear as papules. Very commonly both macules 
and papules will be present at the same time. If it fol- 
lows the macular form, it is apt to appear while the lat- 
ter is fading. The eruption consists of a greater or less 
number of firm, rounded, fleshy, red elevations of the skin 
varying in size from a pin's head to one inch in diameter. 
After continuing unchanged for a certain time they un- 
dergo absorption ; the oldest or central part of the papule 
disappears first, sinks in a little, and becomes scaly. It 
is then that slight pruritus may be complained of. They 
are scattered over the whole cutaneous surface, and often 
appear in well-marked groups. They are prone to re- 
lapses, and sometimes are seen as a relapsing eruption in 
the tertiary stage of the disease, when they do not occur 
as a general eruption, but in groups upon one or more 
regions of the body. According to their size, they have 
received the names of the lenticular and miliary papular 
syphilide, the former being the larger and most common 
eruption. 

The lenticular papular syphilide has hemispherical or 
flattened lesions forming firm, fleshy, lentil to split-pea- 
sized prominences with a smooth and glossy surface. Not 
infrequently the superficial layer of epidermis over them 
is wanting from the central portion, and slightly detached 
around the base, forming a fringe called the collarette of 
Biett. This is regarded as a diagnostic symptom. The 
color of the papules is at first light red ; later it assumes 
a raw-ham color that is best seen on the legs. From the 
knee down they may have a purplish or hemorrhagic ap- 
pearance. They are usually present in great number and 
scattered over the whole body. On the face they are apt 
to locate along the hair-line on the forehead, forming the 
corona veneris. On the scalp they are not very numer- 
ous, and are apt to become papulo-pustules and crust ; or 
they itch slightly and are scratched. The palms and soles 
are usually well covered in any general outbreak of them. 



SYPHILIS. 535 

Here they appear as reddish spots under the thick epider- 
mis. Desquamation is often seen over the papules in the 
palms and soles. Sometimes the eruption is very slight 
in extent, only a few scattered papules being found. 
This syphilide develops slowly, runs a course of one or 
two months, and disappears, leaving pigmentation or 
slightly depressed spots, neither of which is permanent. 

Fig. 62. 



r 



J*: 



Scaling papular syphilide. (After Lassae.) 

In undergoing resolution they may become scaly and form 
a papulo-squamous syphilide, or pustules may form on 
them during their course, and we then have the papulo- 
pustular syphilide. 

While the form of lenticular syphilide just described is 
the typical one, we see at times larger papules, from three- 
eighths to half an inch in diameter, forming the large, flat 
papular syphilide. This rarely, if ever, is a general erup- 



536 DISEASES OF THE SKIN. 

tion, but is limited to certain regions. It may occur 
alone or with the lenticular syphilide. It usually follows 
the latter or appears when it is fading. It frequently 
comes as a relapsing syphilide, and often appears late in 
the second year. It has a flattened surface and a circular 
outline. The lesions often coalesce and form patches 
which frequently become scaly and resemble psoriasis. 
The scaling is never very great ; the scales are thin and 
adherent, and do not cover the whole patch. They fre- 
quently occur upon the flexor aspect of the extremities, 
and in the bends of the joints. Instead of forming 

Fig. 63. 




Condylomata lata. .(After Taylor.) 

patches by coalescence, the individual papule may enlarge 
at the circumference and become depressed at the center 
and form circinate lesions, whose surface may become 
moist. 

The moist papule or mucous patch is a modified form of 
the lenticular papule, and is simply a papule subject to 
heat and moisture. They are found where two folds of 
skin rub together, as in the peno-scrotal fold, between the 
scrotum and inside of the thigh, around the anus and 
vulva, and upon mucous membranes. They are of circular 
shape and have a flattened surface which is sometimes de- 
pressed in the center. Fresh ones have a bright-red or 



SYPHILIS. 537 

raw appearance, but they soon become covered with a 
dirty whitish coating made up of thickened and softened 
epidermis. About the anus and vulva they form large 
flattened tubercles called condylomata lata. (Fig. 63.) 
They give forth a most offensive odor when not kept 
clean. When in the mouth they form " opaline patches/' 
looking as if the mucous membrane had been pencilled 
with nitrate of silver. They are usually not elevated. 
If at the angle of the mouth, they are generally fissured. 
The mucous patch is one of the most contagious of syph- 
ilitic lesions, the evidence of infection being an initial 
lesion of syphilis, and not a mucous patch. They are 
also at times, especially when they come late in the dis- 
ease, most obstinate to treatment, and inclined to relapse. 

The miliary papular syplulide is much rarer than the 
other form of papular syphilide ; in fact, it is one of the 
least common of the syphilides. It consists of numerous 
pinhead or slightly larger sized conical papules of a pur- 
plish-red hue, either disseminated over the whole body or 
aggregated in groups forming circles or segments of circles. 
They are developed about the hair follicles and have de- 
pressed centers. Many of them may be surmounted by a 
small vesicle or vesico-pustule. This constitutes what has 
been named the vesicular syphilide. Sometimes the lesions 
when closely pressed into patches may be scaly. It may 
be an early lesion or a relapsing later one. In the latter 
case the eruption is not abundant, but in groups. The 
color is brownish-red, and pigmentation and permanent 
pitting are left by the lesions, if they have lasted any time. 
They rarely change into condylomata. Their evolution 
is rapid, being fully developed within tAvo weeks. Pea- 
sized conical papules sometimes are seen among the mili- 
ary ones. 

The diagnosis of the papular forms of syphilis is gener- 
ally easy because other symptoms of the disease will be 
sure to be present and to establish the diagnosis. It is 
possible that error may arise in distinguishing the patches 
of scaling papules from psoriasis, but here the location of 



538 DISEASES OF THE SKIN. 

the patches upon the flexor surfaces of the extremities, and 
over the bends of the elbows ; the scaling not being com- 
mensurate with the patch, but having a red, sharply de- 
fined border about it ; and the well-marked infiltration of 
the patches are all features that would throw out the 
diagnosis of psoriasis. The miliary papular syphilide 
may be confounded with lichen planus or keratosis pilaris, 
but the absence of itching is always in favor of a syphilide, 
and the conical or rounded shape of its papules is in strong 
contrast with the flat, angular, and umbilicated papule of 
lichen planus. The syphilide is also a much more widely 
disseminated eruption than is lichen planus or keratosis 
pilaris likely to be and is never seen confined to the 
anterior face of the wrists as is lichen planus. 

The pustular syphilide is the last eruption belonging to 
the secondary stage that remains to be described. It is 
always evidence of a poor condition of the health of the 
patient who bears it. It may be the first eruption of 
syphilis, or follow the erythematous or papular form, or 
occur later. It may develop from a macular or papular 
syphilide, or occur with either of them. It may occur as 
a relapsing eruption late in the tertiary period. It is held 
by some authorities that it is always the product of infec- 
tion of a syphilide by pus-organisms. The appearance of 
this form of syphilide is not infrequently accompanied by 
fever. It may assume varying forms and sizes to which 
in the faulty nomenclature of the older writers have been 
given the names of non-specific lesions, greatly to the con- 
fusion of the student. Professor George H. Fox has done 
well in discarding all such terms, and in describing two 
forms, the lenticular and miliary pustular syphilide. 

The lenticular pustular syphilide (variola-form) occurs 
as a disseminated eruption of small, hemispherical, pea- 
sized pustules, having a hard, papular base and more or 
less of an inflamed areola. It may develop by the soft- 
ening up of a papule, or be a papulo-pustule from the 
start. In the latter case its outbreak will be marked by 
fever, which is apt to recur with each succeeding outbreak. 



SYPHILIS. 539 

The eruption may be general, or upon certain regions. 
The lesions are discrete, and do not form marked groups, 
although in the pustular eruptions, as in others, it is easy 
for one who looks for them to find groupings in circles 
and segments of circles. A few days after they appear 
they begin to desiccate, and the larger ones may umbili- 
cate. At this stage they become crusted with a dirty- 
yellow, brownish or greenish-brown crust. This falls 
soon and leaves a transient pitting and pigmentation. 
Kelapses may occur. 

The miliary pustular syphilide (acne-form). This erup- 
tion consists of millet-seed- to pinhead-size acuminate pus- 
tules developing generally from papules and occurring in 
small groups of about the size of a quarter- or half-dollar. 
It may occur as a general eruption, but is apt to be more 
marked and lasting on the extremities than on the trunk. 
The lesions, especially when occurring upon the flexor as- 
pect of the joints, are liable to coalesce. They are devel- 
oped in and around the hair follicles, and may be perfor- 
ated by hairs. They are topped with small crusts. The 
eruption lasts two or three months by the outbreak of new 
lesions, unless controlled by treatment. They leave pig- 
mentation and pitting that may remain for several months. 

While these are the two chief varieties of the early 
pustular syphilide, there is another variety that is called 
the impetigo-form syphilide, and occurs most commonly in 
the middle or latter part of the first year of syphilis. It 
may occur as late as in the third year. In it the pustules 
are small and flat, and by confluence an impetiginous crust 
is produced. They may form patches with crusting only 
at the border. This form is met with usually on the face, 
arms, and thighs. A few superficial ecthymatous lesions 
may develop, but ecthymatous lesions are usually late 
manifestations. 

The diagnosis of the pustular syphilide is usually easy 
from the presence of other symptoms of the disease. The 
lenticular form may be mistaken for variola or varioloid. 
It differs from these in the infiltrated bases of the pustules, 



540 



DISEASES OF THE SKIN 



in being composed of lesions of varying size and age, in 
not occurring in the mouth, and in not running a definite 
rapid course. The miliary form might be mistaken for 
acne, but it is never confined to the face, chest, and back 
as is acne, nor does it present comedones, and so great 
multiformity of lesions. 
• 

Fro. 64. 




Annular tubercular sypliilide. (After Taylor.) 



Tertiary Syphilides. The erythematous, papular, and 
pustular syphilides are those eruptions that occur in the 
early months of syphilis and during the first year. As 
we have seen, they may also constitute relapsing eruptions 



SYPHILIS. 541 

later in the disease. Modifications of them may occur 
late in the secondary period or even in the tertiary period. 
Besides these, we have a second group of syphilides that 
occur any time after the first year, and sometimes as late 
as twenty or more years after the initial lesion, when the 
patient may have lost all remembrance of it. To these 
eruptions the name of tertiary or late syphilides is given. 
Their peculiarities have been indicated in a general way 
when writing of the early syphilides. They are the tu- 
bercular, the squamous, the pustulo-crustaceous, the gum- 
matous, and the ulcerative syphilides. Exceptionally 
these eruptions may occur before the second year, when 
they are to be regarded as precocious lesions. 

The tubercular syphilide occurs in the latter part of the 
second year of syphilis, or later. Exceptionally it may 
occur during the first year as a so-called precocious syph- 
ilide. As a rule, the early syphilides cease appearing 
after six or seven months, and then after a varying inter- 
val of rest the late lesions appear. These may never 
come at all, usually as the result of judicious treatment, 
or it may be because of the vigorous resistance of the 
constitution of the individual. Tubercular lesions occur 
in the form of clustered nodules in the deeper part of the 
corium. At first they are of faint red color ; gradually 
they become a dull reel, and later still darker. In size 
they vary from that of a split-pea to that of a hazelnut, 
and constitute firm, elastic, fleshy protuberances. They 
are round, smooth, and somewhat glossy, or flat, rugous, 
and withered. They are frequently scaly. Most often 
they are arranged in circles or segments of circles ; or 
they may be in the form of rings from the first, or in con- 
sequence of the disappearance of the central members of 
the group. (Fig. 64.) There may be but a single group ; 
or numerous groups may be scattered over the body in a 
symmetrical manner. A very frequent location for them 
is the posterior portion of the neck, or the face. The 
later in the course of the disease they occur, the more 
they are apt to form but a single group. If uninfluenced 



542 



DISEASES OF THE SKIN. 



by treatment, tubercles may continue to form for years, 
the old ones disappearing and new ones coming. They 
disappear either by absorption, or by softening or break- 
ing down and forming a sharply cut ulcer with perpen- 
dicular edges and yellow sloughing base. A number of 
the lesions breaking down at once and coalescing, a large 
ulcer Avith scalloped border, indicating its composition 

Fig. 65. 



Squamous serpiginous syphilide. (After Lassak.) 

from single lesions, and with more or less thick greenish 
crust, will form. In either case they leave depressed, 
smooth cicatrices, at first pigmented, but later white. 
They give rise to no subjective disturbances. Rarely do 
they form a general eruption. 

The diagnosis of this form of syphilide is usually read- 
ily arrived at by finding other symptoms of syphilis. Oc- 
casionally it may be confounded with lupus vulgaris and 
leprosy. From lupus it is differentiated by the compara- 
tive rapidity of its course, lupus being a disease of exceed- 
ing slowness of development ; by its occurrence in mature 



SYPHILIS. 543 

years, lupus being a disease of youth ; by its sharp-cut 
round ulcers ; by its thick greenish crusts, and by the 
smoothness of its cicatrices, those of lupus being puckered 
and deforming. Syphilis at times bears a striking re- 
semblance to leprosy when its tubercles are located in the 
eyebrows, face, and ears, but the absence of anaesthesia is a 
positive diagnostic sign against leprosy. Moreover, other 
symptoms of leprosy, such as swelling of the ulnar nerves 
and peculiar brown patches, will be absent. 

The squamous syphilide is not usually described, as it is 
a modified form of either the papular or tubercular lesion. 
In using the term here, I follow Professor George H. 
Fox, and like him adopt it purely on clinical grounds. 
He applies the term to scaly patches of circular or ir- 
regular form that occur after the first year of syphilis. 
These patches are covered with thin horny scales seated 
upon an infiltrated base. We may have one of two 
forms : the discoid, or the circulate. The discoid form 
is almost peculiar to the palms and soles and neigh- 
boring parts, and constitutes the only apparent lesion. 
The round patch of varying size, but with a sharply de- 
fined reddish seam beyond the scaling, and an infiltrated 
base, tends to become serpiginous, creeping over a con- 
siderable portion of the skin. Sometimes while it advances 
at one border, it heals at the other ; at other times it clears 
up in the center, leaving an elevated, scaling marginal 
ring. The ring may be broken and leave a curved line, 
and if two or more of these lines meet, we have a gyrate 
figure. Usually but one palm or sole is involved. The 
skin is apt to crack in the natural creases, and then the 
patient will suffer some pain and discomfort. It is always 
an obstinate lesion to cure, persisting sometimes for months 
or years. The circinateform differs from the just-described 
one in being annular from the first, and in occurring not 
only on the palms and soles but elsewhere on the body. 

The diagnosis of this form of syphilide from a squam- 
ous eczema of the palm is often one of great difficulty. 
The fact that only one palm is affected is always suggestive 



544 DISEASES OF THE SKIN. 

of syphilis. Moreover, in syphilis there is more infiltra- 
tion and much less itching. Indeed, the latter may be 
entirely absent. In syphilis the lesion is often crescentic, 
with sound skin between the horns of the crescent. This 
is never seen in eczema. Psoriasis of the palm is, in most 
cases, not to be thought of as a stumbling-block in diag- 
nosis, as it is exceedingly rare for psoriasis to aifect the 
palms, and then only as a part of a general outbreak of 
the disease. Some writers use the term syphilitic psoriasis 
for the scaly palmar syphilide, but it is a most faulty 
method of nomenclature. 

The pustulo-erustaceous syphilide is characterized by 
large and usually deep-seated pustules or ulcers, covered 
by prominent and peculiar crusts. It is the ecthyma form 
of Taylor and other authorities. It occurs as a late and 
localized form of the disease ; never as a general eruption. 
It may occur as a precocious syphilide. It is seen in de- 
bilitated subjects, and is of gradual development, without 
febrile symptoms as in the pustular syphilide. It has 
preference for the scalp, face, and extremities. It assumes 
three forms, the ecthymatous, rupial, and pemphigoid. 

The ecthymatous form begins as an eruption of one or 
more round, flat pustules of a diameter of one-quarter to 
one-half inch. They may become as large as a silver half- 
dollar. They have a well-marked inflammatory areola and 
a swollen and indurated base. The pus soon dries and 
forms a flat, greenish or brownish-black crust, whose cen- 
ter is sometimes depressed. At first the crust fully covers 
the pustule, but later, either through drying or on account 
of an increase in the size of the pustule, a raw rim is left 
around it. When it is now removed it exposes a typical 
punched-out ulcer with its base covered with sanious pus, 
which rapidly dries into a new crust. Under proper treat- 
ment the pustule heals, and when the crust falls there will 
be left a healed or nearly healed ulcer. A permanent ci- 
catrix is left when healing is completed, which is smooth 
and white eventually. This syphilide is seen most often 
on the legs and arms. If the course of the disease is not 



SYPHILIS. 545 

checked, the crust is cast off by increased suppuration, and 
the ulcerative syphilide is before us. 

The second variety of the pustulo-crustaceous syphilide 
is that which is commonly known as rupia. It differs 
from the preceding variety in being more superficial at 
the beginning and in forming a conical, laminated crust, 
somewhat resembling an oyster shell. It begins either 
as a superficial pustule or a small flattened bulla with no 
inflammatory induration. Upon the primary lesion a 
greenish crust develops, under which ulceration, with 
suppuration, occurs. The margin of the ulceration ex- 
tends a little beyond the original crust. A new crust 
forms upon it, raising up the original one, and this pro- 
cess being repeated, at last a laminated crust is formed. 
When the ulceration extends more rapidly in one direction 
than another it will follow that the crust will be higher at 
one end than at the other. Crusts may form a half-inch 
or more in height, and one or two inches in diameter. If 
the lesions are numerous, they are usually small ; if few, 
large. When these thick conical crusts are removed the 
ulcer is exposed and is less deep than in the ecthymatous 
form. On healing, a permanent, smooth, wdiite cicatrix 
is left at last. 

The third variety of the pustulo-crustaceous syphilide is 
the pemphigoid or bullous form. It is a very rare lesion in 
acquired syphilis, though quite common in hereditary dis- 
ease. It consists in an eruption of superficial, purulent, 
flattened bulla? from one to five centimeters in diameter, 
which tend to dry into thick crusts. They are surrounded 
by a dull-red areola, and are soon covered by dark green- 
ish-black adherent crusts. If the patient be in fair 
health, the ulceration under the crusts will not be deep. 
If the patient be a broken down subject, the ulceration 
may be very deep. It will leave either a pigmented 
atrophic spot, or a pronounced scar, according to the 
depth of the ulceration. 

The diagnosis of the pustulo-crustaceous syphilide is 
usually easy if the disease is known to the observer, as no 
35 



546 DISEASES OF THE SKIN, 

non-specific disease resembles it closely. The so-called 
ecthyma cachedicum is more inflammatory than is the 
ecthymatous syphilide, and more superficial. The bul- 
lous syphilid e often bears a striking resemblance to pem- 
phigus, and can be diagnosed only by a study of all the 
features of the case. 

The gummous syphilide is perhaps one of the most char- 
acteristic of the late lesions of syphilis. It consists in a 
deposit of gummy material in the skin. The distinction 

Fig. 66. 




Gummata. (After Jullien.) 

between some tubercular lesions and a gumma is often 
very indistinct, and made principally by the size. The 
gumma begins in the subcutaneous tissue and involves the 
skin secondarily. It may take the form of a single tumor, 
a group of nodules, or a diffused infiltrated patch. It is 
nearly always a late lesion, and while it may undergo ab- 
sorption it possesses a strong tendency to break down and 
ulcerate. (Fig. m.) 



SYPHILIS. 547 

The single tumor begins as a small pea-sized nodule, 
seated in the subcutaneous tissues so deeply as to be ap- 
preciated only by the touch. It grows slowly ; in the 
course of weeks or months it may attain the size of a nut 
and push up the skin over it into an evident tumor, 
which is movable, firm, elastic, painless, and rolls under 
the finger. Increasing in size, it involves the skin, which 
then becomes of a dull reddish color. When the skin 
becomes involved the tumor is no longer movable, and 
soon fluctuation may be felt that would lead the inexpe- 
rienced to open it as an abscess. If he did so, it would 
be a mistake. He would find only a little pus, a gummy 
substance, and some blood. Left to itself, the tumor may 
be absorbed, or it may break down and ulcerate, leaving 
a characteristic deep and round ulcer. The scalp and 
forehead are the chosen sites for this syphilide, though it 
may occur anywhere. It sometimes attains a large size 
— as large as a hen's egg. When this lesion occurs as 
a precocious syphilide it is usually of small size and 
multiple. 

When gummata occur in the form of grouped nodules 
the skin befoveen them is apt to become infiltrated with a 
gunmiatous deposit, and the patch will present the dull 
brownish-red color of the late syphilides. The individual 
members of the group run a course similar to that of the 
isolated gumma, but do not attain its size. When they 
break clown they form a large irregular ulcer. This 
variety of the gumma is frequently met with upon the 
scalp, the nose, the outer aspects of the extremities about 
the joints, and around the lower portion of the leg and 
ankle. Diifuse gummatous infiltration of the skin prob- 
ably precedes all serpiginous ulcerations. Apart from 
this it is rarely seen, and almost always ends in ulceration. 

Other gummatous deposits are known as syphilitic dac- 
tylitis, admirably described by R. W. Taylor, and syph- 
ilitic bursitis, carefully studied by E. L. Keyes. One being 
a bony and the other a synovial disease, they do not here 
concern us. 



548 DISEASES OF THE SKIN. 

The diagnosis of the gumma must be made with care. 
It may simulate other forms of tumors. It is not as hard 
as the sarcoma, nor as compressible as the lipoma, and it 
invades the skin. An abscess is usually attended by pain 
and signs of inflammation, and runs a more acute course 
than does the gumma. 

The ulcerative syphilide, according to George H. Fox, 
merits being described by itself, though in itself only a 
sequence of a tubercular pustulo-crustaceous, or gumma- 
tous syphilide, because in the majority of cases of 
syphilitic ulcers met with it is hard or impossible for us 
to say what the preceding lesion has been. For conven- 
ience, he describes the superficial, the serpiginous, and 
the deep or perforating forms of syphilitic ulceration. 

The superficial syphilitic ulcer is circular, with sharply 
cut edges and dirty-yellowish purulent base. It most 
often follows a pustular or pustulo-crustaceous lesion, and 
may appear comparatively early in the disease, especially 
in debilitated subjects. It is usually of the size of a 
quarter- or half-dollar, and frequently coalesces with other 
ulcers to form ulcerative patches with scalloped margins. 
The face and legs are its most common sites. 

The serpiginous idcer is so called because it tends to 
creep over the surface, healing by a cicatrix as it passes 
along. It may develop from a single circular ulcer heal- 
ing in the middle and at one side, and leaving a crescen- 
tic or " horseshoe " ulcer at the other side, with a sharp 
convex margin, beyond which is a narrow zone of infil- 
tration upon which the ulceration constantly encroaches, 
while healing at its concave border. Or a group of crusted 
pustules or softening tubercles form a number of small 
round ulcers, of which the outer ones usually form a curv- 
ing line. While those in the center and at one side tend 
to heal, new lesions develop at the periphery of the oppo- 
site side, which ulcerate and perhaps coalesce, and so the 
disease creeps on. This form is often observed upon the 
back and on the extremities ; it is not particularly painful, 
and the patient's health may not be impaired. 



SYPHILIS. 549 

The deep ulcerations of syphilis result, for the most 
part, from the breaking down of gummatous deposits. 
The small ones are crater-like in shape. Often the open- 
ing of the softened tumor is smaller than the softened 
mass, and it is not infrequent to find the cavities of adja- 
cent tumors running together subcutaneously. 

Ulcerative syphilides sometimes are covered with exu- 
berant granulations. 

The diagnosis of syphilitic ulcers from non-specific ul- 
cers is most important from a therapeutical standpoint. 
A chronic ulcer located anywhere above the middle half 
of the leg is in most cases syphilitic. If it is not, it is 
probably either traumatic, tubercular, or cancerous. The 
traumatic ulcer is acute and highly inflammatory ; of ir- 
regular shape ; has a history of traumatism ; and heals 
rapidly, excepting in very broken-down subjects, under 
simple dressings. The tubercular ulcer, if from broken- 
down caseous glands, has a history of the previous glan- 
dular affection ; is irregular in shape ; often presents a 
number of sinuses and ridges of inflamed tissues ; and 
runs a sluggish course. If it is a lupous ulcer, there will 
be found somewhere in the neighborhood the characteristic 
apple-jelly-like tubercles ; there will be a history of last- 
ing from early life ; the edges of the ulcer will be shelv- 
ing or undermined ; and there will usually be more or less 
deforming cicatrices present. A cancerous ulcer, usually 
an epithelioma, will have a history of beginning in a pim- 
ple, wart, mole, or such like ; will be irregular in shape 
with an uneven floor ; will be apt to be attended by lan- 
cinating pain ; will usually be a single lesion, located on 
the face ; and will have a raised, waxy, rolled-out border 
over which delicate blood vessels will be seen to course. 

The diagnosis of ulcers of the leg lies between one of 
syphilis and of varicose dermatitis. If the ulcer is irreg- 
ular in shape with shelving edges, rather superficial, sur- 
rounded by a brawny, infiltrated, brownish or dark-red 
tissue with more or less scaling, and there are varicose 
veins above it, we have to do with the so-called varicose 



550 DISEASES OF THE SKIN. 

ulcer. This is in sharp contrast with the round, or scal- 
loped bordered, deep, punched-out ulcer with perpendic- 
ular edges and greenish base, around which there is but 
a small zone of redness. The diagnosis of syphilis is 
strengthened when we find a number of ulcers, or the 
cicatrices of old ulcers. As a rule the syphilitic ulcer is 
located on the posterior surface of the upper half of the 
leg, while the varicose ulcer is on the anterior surface of 
the lower third of the leg. The diagnosis from a trau- 
matic ulcer has already been given. 

Over the pigmentary syphilide there has been no little 
discussion. By this term is not meant pigmentation fol- 
lowing a syphilide which is sufficiently common, and due 
to a staining of the skin with hsematin ; but a true pig- 
mentation without antecedent lesion, and is most always 
seen on the sides of the neck, and in women. It is com- 
posed of irregularly round or oval spots, one-eighth of an 
inch to one inch in diameter, with ill-defined margins, 
and cafe-au-lait color, which does not fade on pressure. 
The color may be very faint. They may be discrete or 
confluent. When they are very numerous they have been 
compared by Fournier to a " network of lace with large 
meshes/' It is one of the rarer manifestations of 
syphilis. 

General Diagnosis of Syphilis. Having now 
studied briefly the various cutaneous lesions of syphilis, 
we are prepared to state those general features of the 
syphilicles that serve to distinguish them from other dis- 
eases of the skin. 

One marked feature of them is that they do not itch. 
Itching does occasionally occur with the scaling papular 
syphilide ; and in some cases the patient will complain of 
an itching of the skin that is quite independent of syphilis, 
but in themselves they do not itch. 

The early eruptions of syphilis are general and exhibit 
a marked polymorphism, many different lesions being often 
present at the same time ; as, for instance, macules, papules, 
and pustules. The late eruptions exhibit a strong tend- 



SYPHILIS. 551 

ency to grouping of the lesions in circles and segments of 
circles. 

The color of the lesions is peculiar, and perhaps may be 
best described as that of raw ham, though the classic term 
is " copper." This color is by no means always present. 
It is not seen in the early bloom of the early lesions, but 
is pretty sure to be found in those that have existed for 
some time, and in the late lesions. The color of a lesion 
on the legs, it must be remembered, must not be regarded 
for purposes of diagnosis ; it is upon the arms, face, trunk, 
and thighs that we must look. 

Painlessness is often a suggestive symptom pointing 
toward syphilis when we have to decide as to the nature 
of an ulceration. 

It is well not to lay too much stress upon the history of 
the case in making up our mind as to a late syphilide, 
because with the best intentions the patient may forget 
having had an insignificant initial lesion some twenty, or 
perhaps thirty, years before. 

Space will not permit of our here detailing the differ- 
ential diagnosis between syphilis and the many diseases 
which it may simulate from time to time. For this the 
reader must be referred to the sections upon eczema, 
psoriasis, lupus, alopecia, etc. 

Etiology. That acquired syphilis is due to contagion 
we know. Further than this we know little of certainty. 
Various attempts have been made to prove its bacillary 
origin, by Lustgarten and others, but at present the best 
authorities are by no means agreed upon the correctness of 
this theory. 1 We can, in the meantime, speak of its being 
due to a specific virus. The microbian theory is also ap- 
plied to all pustular syphilides, and we are taught that 
they are the result of an infection of the specific lesion by 
the pus-coccus. 

Hereditary Syphilis. Before entering upon the study of 
the treatment of syphilis, we must stop a while to consider 

1 For a good study of the probable origin of syphilis consult Finger, 
Archiv Derm, und Syph., 1890, p. 331. 



552 DISEASES OF THE SKIN. 

hereditary syphilis. This differs from the acquired form 
in having no initial lesion, the disease being acquired in 
utero from either one or both parents. We cannot enter 
upon a discussion of the many conflicting theories as to 
whether or not the child is diseased on account of spring- 
ing from a diseased ovum, or spermatozoa ; or the possi- 
bility of the disease, acquired by the mother after her 
pregnancy, reaching the foetus through the placental cir- 
culation ; or like interesting questions over which the bat- 
tle rages. For us now it suffices to make the bald state- 
ment that the disease may be acquired from one or both 
parents. It is most sure to be acquired from the mother, 
and it may be inherited by the foetus from a mother in- 
fected some months after conception. It is possible for a 
woman to show no signs herself of syphilis, and yet to 
give birth to a syphilitic child. It is exceedingly rare 
for the apparently healthy mother of a child hereditarily 
syphilitic to be infected by it. As a result of syphilitic 
infection in utero, the child may be born prematurely, and 
dead ; it may be born at term, dead, and showing specific 
lesions ; or it may be born alive with some syphilitic erup- 
tion ; or, as is commonly the case, the eruption may not 
appear before the second or third week. Miller, 1 from a 
study of one thousand cases of congenital syphilis in a 
foundling hospital in Moscow, found that the first appear- 
ance of the disease was in the first month of life in 64 per 
cent, of the cases ; and in the second month in 22 per 
cent. In congenital syphilis there is a marked absence of 
that sequence of events more or less observed in acquired 
syphilis, but the diagnosis is usually quite as easy. The 
earliest eruption to appear, as to point of time, is, accord- 
ing to Miller, the bullous syphilide, which he met with 
in 25 per cent, of the cases. One of the earliest and most 
characteristic symptoms of hereditary syphilis is " snuf- 
fles," due to an ozsena, which gives the child great dis- 
comfort by interfering with breathing and nursing. 

The erythematous syphilide is, according to Taylor, the 
1 Jahrb. der Kinderheilk., 1888, xxvii., Heft 4. 



SYPHILIS. 553 

most frequent and earliest eruption ; according to Miller, 
it occurs in but 45 per cent, of the cases. It begins on 
the lower part of the abdomen as minute round or oval 
spots, that disappear under pressure at first. It invades 
the whole body within a week, when the lesions will no 
longer fade under pressure, but assume the characteristic 
syphilitic color. One form of the erythematous syphilide 
in children is seen upon the inside of the thighs, about 
the anus, and on the buttocks, and may extend down to 
the feet. It is patchy in character, the patches being 
either of small size, or large by the coalescence of several 
smaller ones. It differs from intertrigo by its patchy 
character, by its darker color, and by its wider distribu- 
tion. 

The papular syphilide and its modified forms of the 
mucous patch and the condylomata lata are common con- 
genital lesions. The lenticular syphilide, large and small, 
is met with far more frequently than the miliary papular 
syphilide. It is usually a symmetrical and general erup- 
tion. It may be smooth or scaly, and always has the 
raw-ham color. Mucous patches are very often at the 
junction of the mucous membrane and the skin, as on the 
lips or anal orifice. The movements of the parts will 
give rise to painful fissures, rhagades, which constitute 
a sign of hereditary syphilis as characteristic as the 
" snuffles." These rhagades Miller met with in 70 per 
cent, of his cases. Mucous patches also occur in the 
cavity of the mouth. Condylomata lata occur where two 
skin surfaces rub together, and especially where there is 
more or less moisture, as about the anus and genitals, in 
the groins and axilla?, and between the fingers and toes. 
Their color is usually grayish-pink to dark-brown ; their 
size varies greatly, and their surface is flat, or fissured and 
ulcerated, and exudes an offensive secretion. They are 
characteristically located when at the angles of the mouth, 
in combination with mucous patches in the mouth with 
rhagades between. 

The pustular syphilide may be general, but is usually 



554 DISEASES OF THE SKIN. 

most pronounced on the thighs, buttocks, and face. It 
shows a tendency to group about the mouth. It is usually 
indicative of profound syphilization. The pustules may 
leave scars. Ecthymatous pustules may develop, but 
usually not till late in the disease. 

The vesicular syphilide is a rare form of early congenital 
syphilis of severe type. It is never general, but appears 
as groups of closely packed together vesicles upon the 
chin, about the mouth, or on the nates, forearms, hypo- 
gastrium, or thighs. They are seated upon infiltrated, 
brownish-red bases. The larger vesicles may be seated 

Fig. 67. 




Hutchinson's teeth. 

upon papules. This eruption is apt to be associated with 
a pustular or bullous syphilide. 

The bullous syphilide, unlike what obtains in adults, is 
comparatively common in congenital infantile syphilis. 
Miller found it in twenty-five per cent, of his cases. It 
frequently exists at birth or as the earliest syphilide, and 
is indicative of a severe form. It is most commonly seen 
on the palms and soles, which are often covered with the 
lesions, while few, if any, are on the trunk. The face is 
a favorite location for the eruption. They are either tense 
or flaccid, and at first have sero-purulent contents that 



SYPHILIS. 555 

soon become purulent. They are seated upon a raw-ham 
colored infiltrated base. Hemorrhage into them not in- 
frequently occurs.. When they rupture or dry up they 
exhibit an unhealthy-looking ulceration that soon becomes 
covered with a greenish crust. Some of them may dry 
up with little, if any, ulceration. It rarely relapses. It 
differs from pemphigus in occurring upon the palms and 
soles, while sparing the trunk, and in the profound ca- 
chexia and the presence of other signs of syphilis. 

The tubercular syphilide is not common, and is always a 
late lesion. While it may be seen as early as the sixth 

Fig. 68. 




Dactylitis. (After Bergh.) 

month, it is more apt to occur much later as a relapsing 
syphilide. In appearance and course it resembles the 
same lesion of acquired syphilis. 

The gummatous syphilide is also a late manifestation of 
the disease, and is sometimes met with in early adult life 
as a lesion of congenital syphilis. 

Kaposi regards as a special and characteristic symptom 
of hereditary syphilis a diffused infiltration of the palms 
and soles, the skin of which is uniformly brownish-red, 
dry, shiny, and fissured. 

Besides the skin-lesions the infant bears certain unmis- 
takable signs of syphilis. It has a marked pallor, and, 
no matter how blooming it may appear at first, it soon 
loses flesh and assumes " an old man " countenance. It 
has a characteristic, hoarse, toneless cry, which once heard 
will be remembered. Its hair is scanty, its nose is apt 



556 DISEASES OF THE SKIN. 

to be flattened, and altogether it is a most woebegone- 
looking object. The skin eruptions usually occur within 
the first six months of life, and if the child can be brought 
through that period it may suffer no more. Nevertheless, 
congenital syphilis, like the acquired disease, may be latent 
for years to crop out once more. The victims of congen- 
ital syphilis sometimes show the notched or peg-shaped 
teeth regarded by Hutchinson as a certain sign of the dis- 
ease. (Fig. 67.) This appearance is presented by the 
second set of teeth only, and is not absolutely diagnostic, 
as the same has been met with in scrofula. The two mid- 
dle upper incisors are those which are depended on for 
diagnosis. " They are small, often converging, some- 
times diverging. The cutting-edge of the teeth is some- 
times narrowed, rounded off. They are stunted and badly 
developed, often marked with seams in front, and of a 
dirty-brownish color, but their chief peculiarity is found 
in their edges, which, being thin when cut, break off cen- 
trally, leaving a broad, shallow, vertical notch on the lower 
border of the tooth." (Keyes.) It is subject to diseases 
of the bones, one of the most characteristic of which is 
dactylitis. Space will not permit of a detailed description 
of the bone and other lesions apart from those of the skin. 
Treatment. The treatment of syphilis is by the use 
of both constitutional and local remedies, and by a con- 
stant and long-continued watchfulness on the part of the 
physician over the patient's hygiene and general well- 
being. One chief obstacle to the successful treatment of 
a case is the patient's lack of faith in his physician. Most 
patients, just as soon as the eruption for which they sought 
advice fades away, will cease coming to the physician, 
and will pay little heed to his warning that unless they 
keep themselves under medical supervision for three or 
four years they will be liable to serious troubles later on. 
Nevertheless, our first duty is so to instruct them. Then 
before putting the patient upon a regular course of treat- 
ment, we should give him careful direction as to his ex- 
ercise, liberal diet, and bathing, and should stop his 



SYPHILIS. 557 

alcohol, insist upon his taking plenty of sleep, and giving 
up the use of tobacco. This last is not only to put him 
in better condition, but also to prevent mucous patches in 
the mouth. The patient should be cautioned against 
drinking out of public drinking-cups, and apprised of the 
danger of infection of others by means of table utensils, 
pipes, and the like. Now he is ready for his course of 
treatment. 

Constitutional Treatment. The drugs employed and 
found of value in syphilis are chiefly but two, namely : 
mercury and iodine in combination with sodium or potas- 
sium. These drugs are given in varying combination, 
and during varying periods, according to the views of 
different physicians. Mercury is the remedy relied on 
most for combating the disease, and should be used under 
ordinary circumstances by itself alone during the first 
year or two of the disease. The iodides exercise a marked 
control over the ulcerative syphilides, and in the late or 
precocious manifestations of the disease. By some they 
are given continuously or as the sole remedy in late 
syphilis, but the best practice is in favor of their adminis- 
tration either with mercury or instead of mercury for a 
short time. Treatment should be begun as soon as we 
are sure that the patient has syphilis. As an element of 
doubt may often enter into our diagnosis of the initial 
lesion, it is a good general rule not to administer specific 
treatment until the appearance of some secondary symp- 
tom. This plan has the additional advantage of producing 
a moral effect upon the patient, who, if he sees an erup- 
tion upon himself, will be more apt to believe that he has 
syphilis, and to submit himself to a thorough course of 
treatment. 

We will consider first the treatment of early syphilis 
and the use of Mercury. This drug, regarded by the 
majority of physicians as the sheet-anchor in the treat- 
ment of syphilis, is administered, for its constitutional 
effect, by the mouth, by inunction, by fumigation, and by 
hypodermic injection. 



558 DISEASES OF THE SKIN. 

Of these different methods the most frequently em- 
ployed is the first — that is, by the mouth. The salt of 
mercury that I most frequently use is the protiodide, 
otherwise called the green iodide. This may be exhibited 
either in pill, tablet triturate, or granule ; and as the tab- 
let triturate is easily obtainable, very reliable, and quite 
inexpensive, my preference is for that preparation. Keyes 
prefers the granules of French manufacture, and says that 
the very objection raised by many authorities to the use 
of the protiodide, namely, its irritant effect on the intes- 
tinal tract, is its shining virtue, because instead of giving 
warning of intoxication by causing salivation, it does so 
by causing diarrhoea. The dose to begin with should be 
from one-sixth to one-fifth of a grain three times a day 
after meals, and the number of pills increased every third 
or fourth day until there is a little " colicky diarrhoea." 
The dosage should be then continued at the same number 
of pills, until the symptoms are controlled. Then we 
can reduce it to half the number. It may be necessary to 
give a little opium at the same time with the mercury in 
order to control the diarrhoea if it is deemed advisable to 
continue at the point of full tolerance, and this not only 
with the protioclicle but with other salts. Practically the 
daily dose of the protiodide may be put at four or five of 
the one-fifth-grain tablets, and three or four of the quarter- 
grain ones, and opium is rarely called for. 

Many prefer to use metallic mercury, hydrarg. cum 
creta, or calomel in the dose of one or two grains two or 
three times a day after meals, increased every three or 
four days sufficiently to influence the eruption. Salivation 
is, in the general run of cases, to be avoided. Some au- 
thorities prefer to combine a tonic with the mercury. 
Taylor gives the following : 



M. 



or 



R. Hydrarg. protiodid. , 


gr. viij-x 


Ferri et qiiinise citrat., 


5iss. 


Ext. hyoscyami, 


gr- v j- 


Ft. pil. no. xxx, 





SYPHILIS. 559 

R. Hydrarg. tannici, gr. xv-xxx. 

Quin. sulphat., 3J- 

Ext. hyoscyami, gr. vj. M. 

Ft. pil. no. xxx. 

In severe cases in which it is necessary to get the 
patient rapidly under the influence of mercury, calomel 
in one-tenth-grain doses in the form of tablet triturates 
may be given every hour until the gums become tender. 
Then the calomel should be stopped and the treatment 
continued with a small dose of the protiodide. 

Besides these preparations of mercury we may use the 
bichloride in doses of -^ to yg- of a grain in solution. It 
is usually given in compound syrup of sarsaparilla or some 
bitter enfosion. The most common mode of administer- 
ing it is in combination with the iodide of potassium, the 
so-called mixed treatment, the formula for which will be 
given later when speaking of the treatment of late 
syphilis. The best opinion is in favor of reserving the 
use of iodine until the early lesions are over. The tan- 
nate of mercury is well spoken of in the dose of half a 
grain. Space will not allow of mentioning the other salts 
of mercury that have been recommended. 

The proper quantity for administration having been 
learned by experiment, the drug should be administered 
continuously for from four to six months. 

Where practicable the use of mercury by inunction is 
the speediest and best way of getting the patient under 
the influence of the drug. It may be used from the first 
or at any time during the course of the disease. Its great 
advantages are the promptness with which it acts, and the 
sparing of the stomach and intestinal tract. Its great 
disadvantages are that it is a dirty method, impracticable 
with most patients, as it attracts notice from his friends 
and attendants ; and the difficulty encountered in getting 
the patient to carry out the treatment with thoroughness. 
It is admirable for hospital treatment. The patient is to 
be told to rub into his skin, once a day, a piece of ungt. 
hydrarg. cinereum of the size of a hazelnut, He is to 



560 DISEASES OF THE SKIN. 

divide the mass into two equal parts, and work it in with 
the heel of his hand for about fifteen minutes, while he 
sits before a fire or in a warm room. Before beginning 
the inunctions he is to take a warm bath, or to bathe the 
parts about to be rubbed, so as to open the pores of the 
skin. The first day he is to rub the ointment into the 
bends of both elbows ; the second day, over the sides of 
the chest ; the third day, over the abdomen ; the fourth 
day, inside of the thighs ; and the fifth day, behind the 
knees. That is, he is to choose the parts least covered 
with hair ; and to change the sites of the inunctions so as 
to avoid setting up a mercurial eczema. On the sixth 
day he is to take another bath, and on the seventh day to 
resume inunctions. The treatment is to be pursued until 
active symptoms of the disease are overcome, when all 
treatment may be suspended. A thorough course of, say, 
eighty or a hundred inunctions is said to be often followed 
by a permanent cure. If the inunctions are to be made 
by an attendant, he should wear a stout rubber glove. 
As a substitute for inunction, E. Welander 1 proposes 
spreading about a drachm and a half of mercurial oint- 
ment on the inside of a small pillow tick, and having the 
patient wear this, properly fastened, next the skin over the 
anterior plane of the body, day and night. 

Fumigation is a method which is not used as much now 
as formerly. It requires the use of a special apparatus, 
and a great amount of time and trouble. Inasmuch as it 
possesses no advantage over inunctions, we will say no 
more about it. 

The hypodermatic injection method of administering 
mercury, or rather the deep intra-muscular method, was 
first advocated by Scarenzio in 1854, and of late years 
has been much experimented with. The injections are 
usually made deep down in the gluteal region, behind and 
above the great trochanter. They are usually painful ; 
often followed by abscesses ; require daily or frequent 
visits to the physician's office ; and do not seem to be 
1 Arch. f. Derm, und Syph., 1897, xl., 257. 



SYPHILIS. 561 

followed by sufficiently lasting effects to warrant their 
frequent employment. They are useful where we wish to 
have a very prompt effect from the mercury, as in a 
malignant precocious case of syphilis ; or where the 
stomach must be spared ; or where the disease has not 
yielded to the ordinary plans of treatment. Patients in 
this country seem to object very strongly to their employ- 
ment. A great number of salts of mercury and combina- 
tions have been introduced, each one of which has been 
found by its introducer the best and most reliable. An 
admirable study of them will be found in Hare's System 
of Therapeutics, vol. ii., by Prof. R. TV\ Taylor. Here we 
can indicate, and briefly, but a few. Taylor gives one of 
corrosive sublimate, gr. xl ; glycerin, 5j ; distilled water, 
5iij ; of which twelve drops are used at each injection. 
The albuminate of mercury, dose 15 minims ; the foraia- 
mide (Liebreich), dose one-half to a whole Pravaz syringe- 
ful of a one per cent, solution ; calomel, 1 part, to liquid 
vaseline, 12 parts, dose a half Pravaz syringeful once a 
week ; " gray oil," composed of 20 parts of pure mercury, 
40 of liquid vaseline, and five of ethereal tincture of ben- 
zoin, dose one-third of a syringeful every ninth day ; l 
the salicylate, 15 grains to the ounce, and many others. 
A final judgment as to the comparative merits of the many 
salts cannot yet be given. 

Late Syphilis. If a patient who has not been under 
systematic treatment comes to us with a late syphilide, the 
so-called mixed treatment will be most appropriate to his 
case. As usually administered it is made up according to 
one of the following formulas : 

R. Hydrarg. biclilor., vel \ ._.. 

Hydrarg. biniodidi, J & • J J- 

Potass, iodidi, 5.MJ- 

Inf. gentian co vel 1 ad g. M 

Syr. sarsaparillae co., J ° 

Dose : A teaspoonful three times a day after meals. 

Or, 

1 Leloir and Tavernier : Giorn. ital. d, Mai. Yen. e del Pelle. 1889, 
xxiv., 247. 
36 



562 DISEASES OF THE SKIN, 

R. Hydrarg. biniodidi, gr. ss-ij. 

Ammon. iodidi, 5 SS - 

Potass, iodide, oVJ~5J- 

Syr. aurant. cort., gjss. 

Tr. aurant. cort., 3J. 

Aquae, q. s. ad §iij. M. 

Dose : A teaspoonful, in water, three times a day. (Keyes. ) 

If a patient comes to us with a gumma, an ulcerative 
syphilide, a group of serpiginous tubercular syphilides of 
the tertiary period ; or if any of these or other deep lesions 
threatening destruction of tissue appear early in a case of 
precocious or malignant syphilis ; or if the disease attacks 
the nervous system, the larynx, pharynx, or eye ; in fact, at 
any time when there is need of prompt effects, we must 
administer the iodides. If he has had no mercury for 
some time, it is best to give it to him now either by the 
mouth, mixed treatment, or inunctions, while the iodide is 
administered separately, but at the same time. The iodide 
of potassium is most generally used, and next to it the 
iodide of sodium. There is no set dose for the iodide. It 
is best given in a dose of five grains in solution in water, 
three times a day, before meals, diluted in milk, or Vichy, 
or soda-water ; or some three hours after meals. Delavan 1 
has found that the iodide can be given most satisfactorily 
by putting five drops of a saturated solution in the bottom 
of a small tumbler, with fifteen drops of essence of pepsin, 
and pouring upon it two ounces of warm milk. This is 
to be set away in a cool place, and will form a rennet 
custard, which can be easily swallowed. This is a good 
method when we wish to give nourishment with the medi- 
cine, and the mixture can be given a pleasant taste by 
adding a teaspoonful of sherry wine. 

The dose should be increased by one or two drops each 
day; that is, six drops t. i. d.; then seven drops t. i. d., 
and so on, until the nose runs and the eyes water, or 
some symptom of iodism develops. The most convenient 
method of administration is to have a solution made con- 
taining one grain of the iodide to each drop of the solu- 
J Med. Eecord, 1891, xl., 651. 



SYPHILIS. 563 

tion, so that every drop represents a grain. Most patients 
bear iodine well, but in some even drop doses produce 
iodism. Iodic acne is very often induced, but should not 
cause us to stop using the drug. It is advisable to sus- 
pend the administration of the iodides from time to time, 
and to give mercury, which, after all, must be depended 
on for curing syphilis. 

Now and again we will meet with cases that do not 
improve either under mercury or iodine, but relapse and 
relapse. Such cases should be sent out of town, ordered 
change of air for a time, and put on a purely tonic course 
of treatment. Very often when the patient returns home 
he can take his medication easily, and the previously ob- 
stinate lesions will yield readily. This is but what we 
said at first ; the patient's general condition must all the 
time be carefully watched over. 

Salivation is an unpleasant accident that may occur 
under the use of either mercury or iodine. At one time 
it was quite common ; indeed, mercury was purposely 
pushed so far as " to touch the gums/' and, of course, this 
was often overdone. Its symptoms are tenderness of the 
teeth, so that pain is felt when the jaws are snapped to- 
gether ; the gums are swollen ; there is a metallic taste in 
the mouth ; a fetid odor of the breath ; increased flow of 
saliva by day and night ; all the mucous membranes of 
the mouth are swollen, so much so as to interfere with 
mastication and deglutition, and in very bad cases there 
may be ulceration, loosening and fall of the teeth, and 
caries of the bones. 

Prevention is always better than cure, and to this end 
we should see that our patient's teeth are in good order 
before beginning treatment, and direct him to wash his 
mouth frequently with chlorate of potash solution, ten or 
fifteen grains to the ounce, or one of alum, and to keep 
his teeth clean. The patient should be seen frequently at 
first, so as to stop the mercury before salivation attains 
any serious degree. Salivation having begun, the mercury 
must be stopped, and the potash solution in same strength 



564 DISEASES OF THE SKIN. 

may be continued, and one or two drachms of it swallowed 
during the day. Dilute solutions of Labarraque's solu- 
tion, or permanganate of potash, or other astringent, may 
be used for a gargle and mouth-wash. A laxative should 
be administered, the patient kept warm in bed, and, if 
necessary, an anodyne given. 

Duration of mercurial treatment. How long the patient 
should take mercury is a question, the answer to which is 
very variously given by different authorities. Keyes puts 
it at from eighteen months to four years. Taylor says " at 
least two years to two years and a-half, counting from the 
date of the commencement/' but he advocates intermis- 
sions of from two to three months, iodide of potassium 
being given in the meantime. Schwimmer l advocates 
giving mercury for two or three months, and then one of 
the iodides for two months ; after four or five months of 
treatment making a pause of two or three months, treat- 
ing any local lesion locally, and then repeating the course. 
Fournier 2 usually administers mercury for six to nine 
weeks ; then pauses six weeks ; then gives another six 
weeks' medication. During the first year he puts the pa- 
tient through four courses ; during the second year, three 
courses ; and during the third year, two courses. During 
the fourth year he gives the iodide alone for six weeks, 
with corresponding intervals. Crocker advises stopping 
mercury about every six weeks to give the iodide for a 
week or ten days. At the end of six months, if the 
patient has been free from symptoms for two or three 
months, a month's pause may be made, to be followed by 
a six weeks' course of mercury. And so through the first 
year. During the second year he alternates a six weeks' 
mild mercurial course with a one or two weeks' course of 
the iodide. If still free from lesions, treatment may be 
suspended until some symptom crops out. 

Against these advocates of long-continued mercurial 
treatment there are others, no less eminent, who advocate 

Second Supplement to the Monatshefte f. prakt. Dermat., 1888. 
2 Gaz. desHop., 1889, No. 103. 



SYPHILIS. 565 

the administration of mercury only during the duration of 
the symptoms, and for a few months afterward ; then they 
advise to suspend all treatment until some new outbreak 
of the disease calls for it. In combating so insidious a 
disease as syphilis, it seems to me wisest to err rather on 
the side of too long continued treatment than on that of a 
too short course. 

Local Treatment. While internal treatment by 
mercury and the iodides is quite competent to remove the 
syphilodermata, their disappearance can be materially 
hastened by local treatment by means of mercurial ap- 
plications. Ointments of metallic mercury, of the am- 
moniate, the red oxide, and the oleate, with solutions of 
the bichlorides, are the preparations most generally em- 
ployed. 

Many attempts have been made to abort syphilis by ex- 
cision of the initial lesion, or its destruction by means of 
caustics. These have been failures in most instances. 
This is not to be wondered at in the light of R. W. 
Taylor's recent studies, 1 which show that " in the very 
first days of syphilitic infection the poison is deeply rooted 
beneath the initial lesion, and extends far beyond it, in- 
fecting all the parts beyond, even to the root of the penis." 
The initial lesion should be dressed with iodoform or 
calomel, or kept covered with dry lint powdered with 
either of these. 

It may be said that in all the early and generalized 
syphilides local treatment needs practically to be applied 
only to lesions on exposed parts ; that is, face, neck, hands, 
and wrists. The erythematous syphilide is usually so 
ephemeral that no local treatment is necessary. Mercurial 
baths may, however, be used for general outbreaks of 
syphilis. If the erythematous lesions persist upon the 
exposed parts, their departure can be hastened by the use 
of the ointment of the ammoniate of mercury rubbed in 
morning and night. The same ointment may be applied 
to the papular syphilide. A still more prompt effect can 
!Med. Eec., 1881, xl., 1. 



566 DISEASES OF THE SKlN. 

be produced, if the patient can be seen often enough, by 
the physician touching each lesion with a solution of the 
bichloride of mercury in alcohol three to five grains to 
the ounce, according to the size of the lesions and the pro- 
fuseness of the eruption. Of course, if the eruption is 
very profuse, this plan cannot be followed. It is most 
applicable to a sparse and relapsing eruption. The mucous 
patch should be touched with the nitrate of silver stick or 
with an aqueous solution of chromic acid, 10 grains to 
the ounce. Condylomata are best treated with dusting 
powders, preferably calomel freely applied and covered 
with absorbent cotton. 

The squamous syphilide of the palms and soles is often 
obstinate, but will usually yield to the persistent use of 
mercurial ointment. Sometimes it will be necessary to 
soften the part by having the patient wear sheet rubber 
next the skin for several days, and then use the ointment. 
If it is covered with a very much thickened epidermis, we 
may have to remove this by using salicylic acid as in 
chronic squamous eczema. Mercurial plaster worn con- 
tinuously is efficient. 

The tubercular syphilide occurring discretely can be 
touched with the bichloride solution already mentioned. 
When in groups it is best treated by means of mercurial 
plaster. 

The gumma may be covered with mercurial plaster or 
ointment. It should not be incised unless it shows un- 
mistakable evidences of containing pus. 

Ulcers following whatever lesion may be covered with 
mercurial plaster or ointment, or dressed with iodoform 
or aristol. If they become sluggish, they may require 
stimulation just as a simple ulcer does. To this end we 
may touch them with balsam of Peru, or add the same to 
our mercurial ointment. Some ulcers will do best under 
the treatment applicable to a simple ulcer, while the 
iodide of potassium is pushed. 

Treatment of Congenital Infantile Syphilis. 
The most popular method is to spread upon pieces of 



SYPHILIS. 567 

flannel a piece of mercurial ointment of about the size of 
the end of the finger, and tie this one day over the elbows ; 
another day over the groins ; another, over the knees ; 
and another, over the abdomen, allowing the movements 
of the child to work the ointment into the skin. Or 
hydrarg. cum creta, one grain three times a day, may be 
given by the mouth. Monti l recommends the following : 



K . Calomel pur. , 
Ferri lactatis, 
Sacch. alb., 

Ft. in pulv. no. x. 

Sig. 1-4 powders daily. 



M. 



The greatest attention must be given to the hygiene of 
the child, and to its diet. Cod-liver oil should be given 
along with the mercurial. The nose must be kept clear, and 
if this is not practicable the child must be fed with a spoon. 
After the disappearance of symptoms, put on tonics, one 
of the best being the syrup of the iodide of iron. In all 
other respects the treatment of infantile syphilis is the 
same as that of the acquired form. Kaposi commends 
the tannate of mercury for children ; dose, J gr. to f gr., 
t, i. d. 

Prognosis. The prognosis of syphilis as seen at the 
present time and in this country may be said to be good. 
Many cases go no farther than a general erythematous or 
papular eruption, even when untreated. In one of robust 
health the disease is usually readily manageable. In de- 
bilitated subjects it sometimes proves intractable. The 
worst feature of the disease is the great uncertainty of its 
course, no one being able to promise confidently, no mat- 
ter with what treatment, that relapses and late visceral 
syphilis will not occur. Therefore, the prognosis should 
be guarded, while it is remembered that rare cases of sec- 
ondary infection attest the possibility of complete recovery. 

The prognosis of congenital syphilis is not as good as 
is that of the disease as it affects adults. Many, perhaps 
most, of the cases seen in public institutions die. In pri- 
^rchivf. Kinderheilk., 1885, vi., i. 



568 DISEASES OF THE SKIN. 

vate practice more can be done, and we should always 
count upon the remarkable reparative powers of child- 
hood in making our prognosis. A great deal will depend 
upon the inborn vigor of the child. 

Syringomyelia (Si 2 r-i 2 n-go-mi-el r -i 2 -a 3 ) is a disease of 
the spinal cord, the consideration of which belongs rather 
to the neurologist than the dermatologist. It interests us 
because various cutaneous lesions occur during its course, 
such as glossy skin, hyperkeratosis, hyperidrosis, and pa- 
ronychia with necrosis of the phalanges ; and because in 
some phases it resembles certain stages of leprosy. 

Syringo-cystadenoma. See Epithelioma, multiple be- 
nign, cystic. 

Tache Atrophique. See Atrophoderma. 

Tache Bleue. See Pediculosis. 

Tache Cafe-au-lait. See Nsevus. 

Tache Congenitale. See Nsevus. 

Tache de Feu. See Nsevus. 

Tache Hemorrhagique. See Nsevus. 

Tache Hepatique. See Chloasma. 

Tache Ombrees. See Pediculosis. 

Tache Pigmentaire. See Nsevus. 

Tache Vasculaire. See Nsevus. 

Tache Vineuse. See Nsevus. 

Tan. See Lentigo. 

Tanne. See Acne. 

Tattoo. These well-known stainings of the skin by 
means of India-ink, vermilion, charcoal, and gunpowder, 
although at first objects of pride to the boy or girl, later 
are apt to become objects of aversion. They are very 
difficult to remove ; indeed, it is almost impossible to re- 
move them if they are at all extensive. Patient perse ver- 



TELANGIECTASIS. 569 

ance in going over and over the small ones, that cannot be 
excised, with the electronic needle will sometimes greatly 
lessen them, though, of course, we thereby substitute a 
white cicatricial spot for a colored one. The needle should 
be introduced perpendicularly to the skin and deeply, and 
numerous punctures arranged in rows thus made. This, 
of course, is a very slow procedure. Powder-grains may 
be removed by Keyes's punch, by making a half turn over 
them, and then snipping off the small piece with the 
scissors. (Fig. 69.) 

Fig. 69. 




Ohmann-Dumesnil l recommends thrusting into the 
stain a bunch of six to ten very fine cambric needles tied 
tightly together with silk thread after dipping them into 
the glycerole of papoid. In this way the whole tattoo- 
mark is to be gone over. It may have to be gone over a 
second time. 

J. Brault 2 recommends tattooing the marks with a solu- 
tion of 30 parts of chloride of zinc and 40 parts of steril- 
ized water. The superficial eschar falls in five to ten 
days. The process may have to be repeated several times. 

Teigne Faveuse. See Favus. 

Teigne Granulee. See Pediculosis. 

Teigne Imbriquee. See Trichophytosis corporis. 

Teigne Pelade. See Alopecia areata. 

Teigne Tondante seu Tonsurante. See Trichophytosis 
capitis. 

Telangiectasis (Te 2 l-a 2 n-ji 2 -e 2 k'-ta 3 s-i 2 s). This is an ac- 
quired dilatation of the blood vessels. The condition is 

1 New York Med. Jour., 1893, Mi., 544. 

2 Ann. de derm, et syph., 1895, vi., 33. 



570 DISEASES OF THE SKIN. 

Avell seen in rosacea. But it seems to me best to reserve 
the term for those cutaneous lesions in which acquired 
dilatation of the blood vessels of the skin is the only con- 
dition present. 

Symptoms. The most common form of the disease is 
what is vulgarly called " spider cancer " or ncevus araneus. 
It occurs in nearly all cases upon the cheeks, near the 
eyelids or bridge of the nose, but may occur anywhere. 
It is usually a single lesion, and consists in a small, cen- 
tral, bright-red, slightly raised dot from which radiate fine 
red lines. They sometimes become quite large, though 
usually not more than a half-inch in diameter. This form 
is seen in women and children. It occasionally follows 
some slight injury, but very often seems to come spontane- 
ously. 

Telangiectases in the form of simple dilated blood ves- 
sels of varying size and shape are often seen. Under the 
same heading Crocker places those slightly convex or flat, 
hemp -seed-sized, raised, bright crimson, or purplish spots 
met with in old people. Their favorite site is the upper 
part of the trunk, neck, and face. 

Etiology. They sometimes are the result of some 
slight injury as the prick of a pin or a mosquito bite. 
Sometimes they are due to continued congestion of the skin 
from disease of the internal organs. In other cases they 
result from a chronic inflammatory disease of the skin. 
They are very common upon the trunk in advanced life. 

Treatment. The treatment of telangiectasis is simple. 
It is only necessary to introduce the electrolytic needle 
into the red central spot, and turn on a current of about 
two milliamperes. The mode of operating is similar to 
that used in destroying superfluous hair, and is described 
in the section on Hypertrichosis. They may be destroyed 
by touching them with a drop of nitric acid, or puncturing 
them with a white-hot needle. 

Tetter. See Eczema. 

Tinea Amiantacea. See Seborrhoea. 



TBICHOXOSIS CAN A. 571 

Tinea Asbestina. See Seborrhoea. 

Tinea Circinata. See Trichophytosis corporis. 

Tinea Cruris. See Trichophytosis corporis. 

Tinea Decalvans. See Alopecia areata. 

Tinea Favosa. See Favus. 

Tinea Furfuracea. See Seborrhoea. 

Tinea Imbricata. See Trichophytosis corporis. 

Tinea Kerion. See Trichophytosis capitis. 

Tinea Nodosa. This is a condition of incrustation of 
the hairs with a fungous growth. The hair follicles are 
unaffected, and the hair is firmly seated in them. The 
hair may be simply incrusted or it may be split. The free 
end of the hair is more affected than the proximal end. 
The spores composing the incrustations are similar to the 
trichophyton, but larger. It is often seen on the axillary 
hairs. 

Tinea Sycosis. See Trichophytosis barbae. 

Tinea Tondens. See Trichophytosis capitis. 

Tinea Tonsurans. See Trichophytosis capitis. 

Tinea Trichophytina. See Trichophytosis. 

Tinea Versicolor. See Chromophytosis. 

Trichauxis. See Hypertrichosis. 

Trichiasis (Trrk-r-a'-srs). This is a congenital or ac- 
quired displacement of the cilise so that they point back- 
ward and scratch the cornea. Both lids of both eyes are 
usually affected. The best treatment is the destruction of 
the hair by means of the electrolytic needle, as described 
in the section upon Hypertrichosis. 

Trichomycose Noueuse. See Piedra. 

Trichomycosis Nodosa. See Leptothrix. 

Trichonosis Cana vel Discolor. See Canities. 



572 DISEASES OF THE SKIN. 

Trichonosis Furfuracea. See Trichophytosis capitis. 
Trichophytie Circinee. See Trichophytosis corporis. 
Trichophytie Sycosique. See Trichophytosis barbae. 

Trichophytosis (TrPk-o^fPt-o'-sPs). A contagious dis- 
ease of the skin and hair, occurring most often in chil- 
dren, due to the invasion of the epidermis by the tricho- 
phyton fungus, and characterized by the formation of 
circular or annular scaly patches, and partial loss of hair. 

As its name indicates, this is a disease produced by the 
trichophyton fungus. It may find lodgment and grow 
on the general cutaneous surface, in the scalp, beard, or 
nails — that is, in the epidermic structures. In these dif- 
ferent localities it develops so differently as to produce 
very different clinical pictures. I shall describe each one 
by itself and give its differential diagnosis, treating all 
matters of etiology and treatment collectively. 

Trichophytosis Corporis. Synonyms : Tinea circinata ; 
Herpes circinatus ; (Fr.) Herpes circine, Trichophytie cir- 
cinee ; (Ger.) Scheerende Flechte ; Ringworm of the body. 

Symptoms. This is the simplest and most readily cured 
of all the forms of ringworm. It begins as a small, pale- 
red, slightly raised spot, which, growing, spreads out into 
a round, sharply defined, scaly patch ; then it clears up in 
the middle, becomes ring-shaped, and advances with a 
raised border that may be vesicular ; or crusted from the 
drying of the vesicular contents ; or papular and scaly. 
After a time it either ceases to spread, or, enlarging, the 
edge of the ring becomes broken in places. At last it 
undergoes spontaneous involution. There may be but a 
single patch, or there may be a number of patches. If 
two circles meet at their peripheries, they coalesce and 
form gyrate figures. Very often rings do not form, and 
we have only a round, sharply defined, scaly, circular 
patch. The exposed parts — face, hands, and neck — are 
the most common sites for the eruption. In rare cases 
ringworm may be widely disseminated over the body. A 



TRICHOPHYTOSIS CORPORIS. 573 

slight amount of itching is the only subjective symptom, 
and that may be wanting. 

Another form of ringworm of the body is that known 
as eczema marginatum, which is ringworm located in the 
crotch or axilla. It is usually of a more highly inflam- 
matory character than the same disease on other parts of 
the body, and resembles an eczema very closely — in fact, 
it is often complicated by an eczema. The edge of the 

Fig. 70. 




? 



Trichophytosis corporis. 
(From Prof. G. H. Fox's service at the Yanderbilt clinic.) 

patch is sharply denned, raised, scalloped, papular, and 
scaly, while the center may be smooth, or pigmented and 
crusted. The patch often attains large dimensions, run- 
ning down the inside of the thigh, up over the abdomen, 
and backward over the perineum. Usually the inside of 
both thighs is affected. There is considerable itching. 
The same symptoms are presented when the axilla? are 



574 DISEASES OF TEE SKIN. 

affected. There is also a true eczema of the crotch that 
is not due to the trichophyton, but resembles the form 
just described. 

Tinea imbrlcata is supposed to be a very aggravated 
form of body ringworm occurring in tropical countries. 
But Manson l says that it differs from ordinary ringworm 
in affecting a very large part of the body at the same 
time ; in avoiding hairy jDarts, and sparing the hair ; in 
an absence of signs of inflammation ; in not forming a 
single ring, but ring within ring, and recurring in parts 
gone over ; in having large abundant scales ; in profuse 
fungous growth ; in always breeding true in inoculation- 
experiments ; and in occurring only in certain parts of 
the world. 

Diagnosis. Trichophytosis corporis is readily diag- 
nosed, as its appearance is distinctive. Favus of the body 
may spread out into a circular patch, but soon it will show 
the distinctive sulphur-yellow cupped crusts. Psoriasis 
on the body will have a brighter red color ; its scales will 
be more abundant, thicker and brighter ; it will be found 
on the tips of the elbows and over the knees, and will be 
more profuse and disseminated ; and examination of the 
scales will show an absence of fungus. The scaling pap- 
ular syphilide or the squamous syphilide will not itch ; 
there will be no fungus in the scales ; the color will be 
raw-ham ; the base will be more infiltrated ; it will run 
a more chronic course ; and will not yield so readily to 
treatment. Seborrhoza of the chest may occur in rings, 
but its location will suggest its origin ; the skin will be 
greasy, the scales will rub off easily, and there is no fun- 
gus in them. Eczema of the crotch or axilla differs from 
ringworm of the same region in not having a so sharply 
defined and scalloped or festooned border ; in forming a 
more evenly diseased patch with no sound skin in it ; and 
in having no fungus in the scales taken from it. Pity- 
riasis rosea is more widely distributed than is ringworm, 
and spreads more rapidly : it is not so scaly ; has a more 
iBrit. Jour, of Dermatol., 1892, iv., 5. 



TRICHOPHYTOSIS CAPITIS. 5 i 5 

yellowish center ; is usually most abundant on the trunk ; 
shows no fungus under the microscope ; and the eruption 
is made up of both macules and rings. 

Trichophytosis Capitis. Synonyms : l Herpes tonsurans 
seu cireinatus, seu squamosus ; Tinea tonsurans, sen ton- 
dens ; Porrigo furfurans ; Dermatomykosis tonsurans 
(Kobner) ; (Fr.) Herpes tonsurante, Teigne tondante ou 
tonsurante, L'herpes circine parasitaire ; (Ger.) Scheerende 
Flechte ; (Slav.) Kingskurv ; Kingworni of the scalp. 

Symptoms. This form of ringworm is seen almost 
exclusively in infants and children. As puberty or early 
adult life is reached the disease, no matter how long con- 
tinued, and how severe it may be, it tends to get well of 
itself. It begins as a single vesicle or a small, insignifi- 
cant, red, scaly spot that would pass without suspicion of 
its nature unless other cases of ringworm put us on our 
guard. From this small beginning the disease spreads 
peripherally to form a circular patch, which is red, cov- 
ered with grayish scales, sharply defined, perhaps slightly 
elevated, and partially bald. Inspection of the patch will 
show a number of broken-oif stumps of hair with split 
ends. These stumps are characteristic of the disease. 
The hair growing in and about the patch is dry, lustreless, 
split, and brittle. Attempts at epilation break it off, and 
if it is indented with the finger-nail it will take a sharp 
angle and retain it. This shows that it has lost its resil- 
iency. Apparently healthy hairs are sometimes growing 
from the patch. The size of the patch varies greatly. It 
may be no larger than that of a ten-cent piece, or it may 
be so large as to denude a good part of the scalp. These 
large patches are usually formed by the coalescence of 
several small ones, and then they lose their circular out- 
line and become scalloped. There may be but a single 
patch, or there may be a number of them. After attain- 
ing the size of a half-inch to one inch in diameter, the 
patches may remain stationary in size, or increase slowly. 

1 1 can mention here only the more common ones, as their number is 
legion. 



576 



DISEASES OF THE SKIN. 



The most frequent sites are the vertex and parietal regions. 
Pruritus of greater or less degree is usually complained 
of, and it may be the first symptom that draws attention 
to the child's scalp. The course of the disease is exceed- 
ingly chronic. It does not produce permanent baldness. 
This is the typical " ringworm/' as seen in the vast ma- 



Fig. 71. 




Trichophytosis capitis. 1 (Fox.) 



jority of cases. Sometimes, instead of being scarcely or 
not at all raised above the surface of the skin, the patch, 
usually a single one, begins to swell up, becomes raised, 
uneven, and boggy, and we have the condition of things 
described as her ion (which see). Another variety is what 
T T . H. Fox. Skin Diseases of Children, Wood, N. Y., 1897. 



TRICHOPHYTOSIS CAPITIS. 577 

Liveing terms bald tinea tonsurans. This begins as an 
ordinary ringworm, but after a time the hair all falls out, 
the scalp is smooth and without scales, as in alopecia 
areata, and at its border there may be found short broken 
hairs, like those seen in the latter disease. At first this 
change takes place in one patch alone, and we will be 
guided to a right diagnosis of the disease by the appear- 
ances of the other patches. Later, these too become 
altered, and then it would be hard to make the diagnosis 
without the history of there having been scaly patches. 
This is an infrequent form of the disease. 

Still another form is called disseminated ringworm. 
Here the patchy, areated character of the disease has dis- 
appeared, the hair has apparently grown in nicely, and 
there is seemingly only a scurvy condition of the scalp. 
This is a dangerous form, because the child is often re- 
garded as well and yet is quite capable of spreading in- 
fection. Careful examination of the case, by causing the 
child to stand with his back to the physician, and turning 
the hair slowly backward against its direction of growth, 
will show here and there " stumps," and also the presence 
of hairs that stand up from the head for a few moments. 
Normal hair falls quickly back into place, which is not 
the case with hair affected with ringworm. 

A pustular form is sometimes described. It is simply 
a ringworm occurring in a strumous subject, in whom all 
inflammatory skin diseases are prone to assume a pustular 
character. 

Diagnosis. Trichophytosis capitis must be differenti- 
ated from alopecia areata, favus, eczema, seborrhoea, and 
psoriasis. From alopecia areata it differs in being scaly ; 
in not producing perfectly bald patches ; in its much slower 
progress ; in the presence of " stumps ; " and in having the 
trichophyton fungus in the hair, as seen under the micro- 
scope. From favus it differs in the absence of the sul- 
phur-yellow cupped crusts of that disease ; in not having 
such heaped-up asbestos-like crusts ; in forming distinct 
round patches ; in the more brittle character of its hair ; 
37 



578 DISEASES OF THE SKIN. 

in not producing red, smooth, permanently bald spots 
that later become white and cicatricial, and in showing a 
marked, tendency to get well of itself as puberty is reached. 
The diagnosis between them by the microscope is not easy 
without a knowledge of the appearances on the skin. The 
spores of favus are more polymorphous and somewhat 
larger than those of trichophytosis, and its mycelia are 
more abundant than its spores. From eczema it differs 
in the more circumscribed and circular character of its 
patches ; in being less itchy, and in the presence of broken- 
off hairs and stumps. The presence of these broken-off 
hairs and stumps, and of the fungus in the hair and scales, 
will sufficiently distinguish ringworm from, both seborrhoea 
and psoriasis. 

Trichophytosis Barbae. Synonyms : Tinea sycosis, seu 
barbae ; Sycosis parasitaria, seu parasitica ; Herpes ton- 
surans barbae ; (Fr.) Trichophytie sycosique, Sycosis par- 
asitaire ; (Grr.) Parasitische Bartfinne ; (It.) Sicosi para- 
sitaria ; (Eng.) Barber's itch, Ringworm of the beard. 

When the trichophyton invades the beard, at first it 
forms simply a superficial scaly circular patch which in- 
creases in size, just as on the scalp, producing broken-off 
hairs and a partially bald area. There are usually several 
of these areas upon the chin and cheeks. If not checked 
by treatment, we have the more characteristic develop- 
ment of the disease, in which there will be either some 
pustules, pierced by hairs, or else a group of large nodular 
swellings, varying in size from a split-pea to a half-cherry, 
arranged in the form of a circle. There are usually sev- 
eral groups of them. The nodules are prominently raised 
and usually rounded. (Fig. 72.) They are of a con- 
gested red or purple color. They may be hard and scaly ; 
or give exit to a sticky discharge ; or, rarely, suppurate. 
The hair over them is broken, or more or less wanting. 
Usually itching and burning are complained of. 

Diagnosis. The disease is to be differentiated from 
sycosis, pustular eczema, and the tubercular syphilide. 
From sycosis it differs in affecting the lower part of the 



TRICHOPHYTOSIS BARBJE. 



579 



face and sparing the upper lip ; in presenting broken-off 
hair ; in having grouped nodules ; and in the presence of 
the fungus in the hair. Sycosis is more acute in its mani- 
festations, and is characterized by its many discrete pus- 
tules pierced by hair. From eczema it differs in the same 



Fig. 72. 




Trichophytosis barbae. 
(From Prof. G. H. Fox's service at the Yanderhilt clinic. 



points as it does from sycosis and also in being less crusted, 
and in the ease with which the hair can be plucked or will 
break. Eczema is also a disease of the skin and not of the 
hair. The tubercular syphiUde does bear a resemblance to 
trichophytosis barbae at times. It differs in forming but a 
single group, in being of a darker color, and in undergo- 
ing a steady course of development to/ward final recovery, 
leaving, not infrequently, permanent scars. Other symp- 



580 DISEASES OF TEE SKIN. 

toms of syphilis will often be found, and its whole history 
will be different. 

Trichophytosis unguium, or onycho-mycosis, is ring- 
worm, as it affects the nails. It begins as a change in 
color of the nail-substance and with a loss of its trans- 
parency. The nail becomes uneven and thickened, and 
its edge, which is usually the part first attacked, becomes 
raised from its bed by an accumulation of scaly matter 
under it. A progressive atrophy takes place, and at last 
the nail breaks and falls either in part or as a whole. 
There may be but one nail affected, or all the nails, both 
of the hands and feet, may be attacked, then usually con- 
secutively. 

Diagnosis. The appearances presented by the nails 
are so similar to those seen in psoriasis, and other diseases 
in which the nails become atrophied, that a positive diag- 
nosis can be made by the microscope alone, unless there 
should be symptoms of the one or the other disease pres- 
ent elsewhere on the body as a guide. 

Having now described the different varieties of ring- 
worm with their differential diagnosis, we pass on to study 
the factors common to all. 

Etiology. The cause of the disease is contagion with 
the trichophyton fungus. This contagion may be direct, 
from person to person, or indirect by means of brushes, 
towels, clothing, and the like. It is possible that the air 
may become so full of the fungus in epidemics in crowded 
children's asylums that contagion may be by means of the 
fungus lighting upon the head or body. The disease is 
very contagious, much more so than is favus. 

As the disease is quite common in dogs, cats, and 
horses, constituting in them one form of mange, they are 
a very frequent source of contagion. Ringworm of the 
scalp is often communicated by means of brushes and 
headgear. Ringworm of the beard is conveyed by means 
of brushes, towels, and the barber's fingers. Ringworm 
of the nail comes from scratching. Some skins seem to 
furnish a better soil for the growth of the fungus than do 



TRICHOPHYTOSIS UNGUIUM. 581 

others. Children have ringworm of the scalp ; adults 
almost never. There is no peculiarity of constitution that 
predisposes to the disease. It attacks all classes and con- 
ditions of society, though, of course, it is most common 
among the crowded poor. 

Pathology. The trichophyton tonsurans, the fungus 
of ringworm, has its habitat in the epidermic structures of 
the skin. On the general cutaneous surface it is so super- 

Fig. 73. 




m 



m 



ti'Iii 1 




1 . 



Trichophyton tonsurans in hair shaft and follicle. (After Kaposi.) 

ficially located as to be readily destroyed. When it 
attacks the hair and nails it penetrates below the skin in 
their epidermic structures, and is much more difficult of 
cure. 

The fungus (Fig. 73) consists in mycelia and conidia 
(spores), the proportion of which to each other varies ; in 
the hair of the scalp and beard the number of spores far 
exceeds that of the mycelia. Sometimes they are so nu- 
merous as to be crowded together in lines. On the gen- 



582 DISEASES OF TEE SKIN. 

eral surface the mycelia are far more numerous. They 
are long, slender, branched, straight, or crooked bodies. 
The spores are round, small, and refract light. Having 
become lodged in the skin the fungus always sets up a 
certain amount of irritation by its processes of growth. If 
it lands upon hairy regions, it attacks the hair secondarily, 
passing down the walls of the hair follicle to a greater or 
less depth before it penetrates the cuticle of the hair and 
gains access to its substance. Having gained access, it 
vegetates freely and may often be traced throughout the 
whole length of the hair. Robinson and others have 
found the fungus in the peri-follicular tissue. Its pres- 
ence always causes more or less peri-folliculitis, and this 
is much more intense in the beard than in the scalp hair, 
which, together with the looseness of the subcutaneous 
connective tissue in the beard, will explain the reason why 
we have the nodules form there. If the peri-folliculitis is 
very great, permanent baldness may result. In tricho- 
phytosis unguium the fungus grows in the substance of 
the nails. Sabouraud l has demonstrated that there are 
several fungi producing ringworm, the most common being 
the mierosporon audouini, and the trichophyton endothrix 
and ectothrix. C. J. White, 2 repeating Sabouraud's inves- 
tigations in this country, says that 52 per cent, of ring- 
worm in this country is due to the mierosporon, most all 
being on children's scalps. In the hairs the spores are 
small, round, glistening, and placed closely together. 
They are more equal in size than are those of the other 
forms of ringworm. It does not grow well on the skin. 
The other forms of ringworm fungi rarely affect the scalp. 
The trichophyton endothrix in the hair runs in lines par- 
allel to the long axis of the hair. Its spores are quad- 
rangular, with rounded corners, and vary considerably in 
size. It causes most cases of ringworm of non-hairy parts. 
The ectothrix variety most often affects the bearded por- 

l R. Sabouraud, Diag. et Trait, de la Pelade et des Teignes de 1' En- 
fant. Paris, 1895. 

2 Journ. Cutan. and Gen.-Urin. Dis., 1899, xvii., No. 1. 



TRICHOPHYTOSIS. 583 

tion of the face, and causes the deep or suppurating forms 
of ringworm. The spores resemble the preceding, but 
grow around the hairs rather than in them. 

Treatment. There is no disease of the skin much 
more easy of cure than trichophytosis of the general sur- 
face of the skin, and none much more difficult of cure 
than trichophytosis capitis. 

Trichophytosis corporis may be readily cured with al- 
most any slightly irritating and astringent application, 
and by all the antiparasitics. It may be cured by 
means of common ink, or by usiug vinegar in w T hich a 
copper coin has been soaked. We can direct that the 
scales be removed with soap and water, and an ointment 
of sulphur, or ammoniate of mercury, or chrysarobin, or 
pyrogallol be applied, or simply paint the patch with 
tincture of iodine, acetic or sulphurous acid, or a solution 
of bichloride of mercury, three to five grains to the ounce. 
The last is a good method for adults as it does not stain 
the skin, and one application will usually cure the disease. 
It is rather too strong for children. Other applications 
are a saturated solution of hyposulphite of soda ; oleate of 
copper, half a drachm to the ounce of ointment ; and 
salicylic acid, 5 or 10 per cent, strength, which by no 
means exhausts the list. 

Trichophytosis cruris et axillce is not so easy to cure as 
the preceding variety, but it can be cured by any of the 
means detailed above. In using chrysarobiu, here as else- 
where, w T e should bear in mind its irritant qualities. 
Taylor has recommended painting the parts with two to 
four grains of bichloride of mercury in one ounce of tinc- 
ture of benzoin. Hardaway speaks w T ell of modified 
Wilkinson's ointment. Some cases will make a good 
recovery under an ointment containing oil of cade, one 
drachm to the ounce. This is specially good after the use 
of sulphur or other antiparasitic to kill the fungus, as it 
is curative of the eczema that often remains. 

Trichophytosis capitis is the most obstinate form of ring- 
worm to cure. The fungus is present abundantly deep 



584 DISEASES OF THE SKIN. 

down in the skin, and each hair is a separate focus of dis- 
ease. The difficulty we have to contend against is to 
cause our remedies to enter the skin deeply enough to de- 
stroy the fungus. Nature gives us a hint as to the cure 
of the disease when a kerion forms that is not infrequently 
followed by disappearance of the disease. Most of the 
so-called remedies for ringworm are irritants to the skin, 
and do good quite as much by the irritation they cause as 
by their parasiticide properties. 

If we see the case at its earliest stage, we may some- 
times succeed in aborting the disease by the application of 
the bichloride of mercury, five or ten grains to the ounce. 
Usually, when the case is brought to us, it has gone too 
far for aborting it. Then we may sometimes cure the case 
promptly, but most often it is an affair of months and, 
perhaps, years. The first requisite for a cure is faith on 
the part of the patient, so that the second element, persist- 
ency, can come into play ; and then by the persevering 
use of parasiticides a cure may be effected. As each case 
is a source of contagion, steps must be taken to isolate the 
case if it occur in an asylum or school. If it occur out- 
side of an institution, the parents must be cautioned not 
to allow the child's hat or clothing to be worn by any 
other child, and the child must be taken out of school. 
To assure still further the safety of others, an antiparasitic 
must be applied to the child's head, such as a 1 or 2 per 
cent, solution of salicylic acid in alcohol and castor oil. 
The child should also wear a linen cap over the whole 
head. These regulations are difficult to carry out in 
private practice. 

The ringworm patch or patches should be scrubbed 
with soap and w T ater so as to remove all the scales before 
we make any local application. Tar soap is a good one 
to use for the purpose. Then the hair should either be 
cut short, pulled from, or shaved off the patches and for 
about a quarter of an inch about them. Now the case is 
ready for the chosen parasiticide. Whatever is used in 
the form of an ointment or oil it should not be smeared 



TRICHOPHYTOSIS. 585 

over the surface, but worked in, as it were. The reme- 
dies we use are exhibited in the form of ointments, oils, 
varnishes, pastes, solutions, and plasters. It is, unfortu- 
nately, necessary to give a lengthy list of remedies from 
which the reader may select. One of the oldest and 
most used of them is the officinal sulphur ointment, full 
strength or diluted according to reaction. No pustulation 
should be caused by our applications. Here, as else- 
where, when an ointment is mentioned, it is to be under- 
stood that it may be made with lard, vaseline, lanolin 
softened with oil, or plasment (mucilage of Irish moss). 
The last is to be preferred because it is not greasy, sinks 
readily into the skin, and leaves a slight film over the 
patches that prevents, to a certain extent, the escape of 
the spores into the air. The persistent daily use of sul- 
phur ointment, combined with epilation, and scrubbing of 
the patch with soap and water about once a week, will 
cure the disease. Sulphur may also be used in combina- 
tion with other drugs. One of the most efficient remedies is 

R. 01. tiglii, m 3j. 

Ungt. sulphuris, 5J* M. 

This is to be rubbed into the patch once a day until 
symptoms of reaction appear, the patch becoming swollen 
and red. When this subsides the patch will be smooth 
like as in alopecia areata. There is always danger of pro- 
ducing permanent baldness, but thus far in all my cases 
the hair has come in all right. As nothing has yet been 
found to render sulphur soluble in any amount, it must 
always be exhibited in ointment or paste form. Mercury 
is another old stand-by. It may be used as a solution of 
the bichloride in alcohol (grs. j-iij ad Sj), whose applica- 
tion should not be intrusted to anyone but a physician or 
trained nurse. It is to be used two or three times a day, 
its effect carefully watched, and, of course, it should not 
be used to large surfaces. It may be employed as recom- 
mended by Kerley, 1 who reports having cured a number 

»N. Y. Med. Jour., 1891, liv., 396. 



586 DISEASES OF THE SKIN. 

of cases in from two to twenty weeks by using a solution 
made by adding two grains of the bichloride dissolved in 
sufficient alcohol to a half-ounce each of kerosene and 
olive oil, daily rubbed into patches as well as applied all 
over the scalp. When inflammation is caused, the appli- 
cation is stopped, and a simple ointment is used until the 
irritation subsides. Then the bichloride is again applied. 
The scalp is to be washed often. He thinks that a cure will 
be hastened by using a saturated solution of iodine on 
alternate days with a bichloride solution. Crocker thinks 
highly of the bichloride, three grains dissolved in alcohol, 
to the ounce of turpentine. Tincture of benzoin is a good 
excipient for the bichloride, according to Leviseur, 1 who 
recommends the application of it, 1 to 2 parts of Hg to 
300 parts of benzoin, once a week, with the daily use of 
salicylic acid ointment in 10 to 20 per cent, strength. 
All the mercurial ointments are useful, but are not so 
prompt in their action as other remedies. 

The remedies recommended in the treatment of ring- 
worm of the body are all of use in the same disease of 
the scalp, and need not be repeated here. The main mod- 
ification is the epilation that should precede their applica- 
tion. Instead of using tincture of iodine, the English 
authors commend Coster's paint, made of two drachms 
of iodine and six drachms of the light oil of wood-tar, 
which is to be firmly applied with a stiff brush. A black 
crust will form after two or three days, which should be 
removed with the forceps. The part should then be 
washed with soap and water, and the paint again applied. 
Two or three applications may be made of it to an in- 
fant's scalp, or it may be continued longer in children over 
four years of age. 

Ckrysarobin in 10 per cent, strength in traumaticin or 
collodion is good, its tendency to produce dermatitis be- 
ing ever borne in mind. Pyrogallol in 5 to 15 per cent, 
in the same excipients, with or without the addition of 
half a drachm of salicylic acid to the ounce, is a reliable 

JMed. Kec., 1889, xxxv., 594 



TRICHOPHYTOSIS. 587 

preparation, ft-naphthol or hydronaphthol are commend- 
able. One of the neatest methods for treating ringworm 
is that commended by Dockrell, 1 and it has proved useful 
in my hands. He directs that after shaving and washing 
the head with a 5 per cent, hydronaphthol soap and hot 
water, the part is to be dried and covered with strips of 
10 per cent, hydronaphthol plaster so that they overlap 
at the edge. Over all is to be poured some melted 10 
per cent, hydronaphthol jelly. At the end of four days 
the plaster is to be removed, the head again washed, and 
a 20 per cent, plaster applied and worn for one week. 
Finally a ten per cent, plaster is to be worn for ten days. 
If not well then, the process may be repeated. Naphthol 
may be used as a 1 per cent, solution in alcohol, or in the 
form of a paste, as recommended by Kaposi : 2 

R. Naphthol., 1 

Spt. sap. viridis, 2 

Alcohol., 50 
Bals. peruv., 2 

Sulph. loti, 10 M. 

Either may be applied twice a day for two or three days, 
and then followed by a thorough scrubbing with green 
soap. Thymol in 5 to 10 per cent, strength, dissolved in 
chloroform and olive oil, is recommended by Malcolm 
Morris. Formalin is commended by some, but condemned 
by others, on account of the severe irritation it is capable 
of setting up. 

Harrison 3 endeavored to effect entrance of his remedies 
to the deeper parts of the skin by first applying to the 
scalp solution No. 1, composed of half a drachm of po- 
tassium iodide in one ounce of liquor potassse. After a 
few days he applied solution No. 2, composed of three 
grains of corrosive sublimate to one ounce of sweet spirits 
of nitre, or of water. This treatment requires careful 

lancet, 1889, ii., 1110. 

MVien. med. Wocli., 1881, xxxi., 617. 

3 Brit. Med. Journ., 1885, ii., 131. 



588 DISEASES OF THE SKIN. 

watching. Foulis 1 recommends rubbing turpentine into 
the scalp, after cutting the hair, until it smarts. Then it 
is to be scrubbed with 10 per cent, carbolic soap, dried, 
and painted with two or three coats of tincture of iodine. 
When dry the whole head is to be anointed with carbol- 
ized oil, 1 in 20. This procedure is to be carried out 
once a day. Alder Smith has found useful a saturated 
solution of boric acid, as follows : 

R. Ac. boric, 5 1V ; 151 

Athens, gv; 150 

Alcoholis, ad gxx; 600; M. 

It is to be freely applied after washing the head in the 
morning, and two to five times during the day. 

H. B. Sheffield 2 recommends clipping the hair close, and 
applying over the whole scalp once a day for five days 

R. 



Ac. carbolici, \ 
01. petrolati, J 


aa 


Sss; 


65 


Tinct. iodidi, \ 
01. ricini, J 


aa 


5i.i; 


110 


01. rusci, 


ad 


giv; 


500 



M. 

This is to be wiped off with a cloth on the sixth day, 
the hair clipped, and the scalp thoroughly washed with 
green soap. On the seventh day the treatment is to be 
repeated, and so on for three or four weeks, or until no 
more fungus is found and new hair appears. A 10 per 
cent, sulphur ointment is then to be used for a few days, 
and for two weeks afterward 

R . Kesorcin, \ 

lici, / 



Ac. sal icy li 

Alcoholis, 

01. ricini, ad 



5i; 


16 


Si; 


120 
500 



M. 



In very chronic cases and in the disseminated form it 
may be necessary to blister the patch by means of croton 
oil or acetic acid. Croton oil must always be used with 

ilbid., 1885, i., 536. 

2N. Y. Med. Journ., 1898, lxvii., 680. 



TRICHOPHYTOSIS. 589 

caution and to small areas, as it is capable of producing 
permanent baldness. One part in ten of olive oil is usu- 
ally sufficient, but the strength may be increased till we 
have it sufficiently strong to cause a mild degree of pus- 
tulation, when the hairs may be easily plucked. In dis- 
seminated ringworm a drop of the pure oil may be applied 
to each diseased follicle, and as soon as a pustule forms 
the hair should be pulled out. In very obstinate cases 
electrolysis may be practiced to individual hairs, which, 
like the croton oil, will permanently destroy the hair. 

Epilation is of positive value in treating this obstinate 
disease, even though the hair does break off. Some hair 
with its fungus will come out, and the follicular mouths 
will be rendered more open for the entrance of our appli- 
cations, which should always follow epilation. Besnier 
epilates around the patches, and asserts that then the dis- 
ease rarely spreads to neighboring parts. 

Treatment should be continued until there are no more 
stumps or broken-off hairs to be seen ; till the microscope 
fails to reveal any fungus in the hair after prolonged search, 
and until the scalp is no more scaly. It is well to use the 
following : 

R. Hydrarg. ammon., Qj; 3175 

Hydrarg. chlor. mitis, 9ij; 7j50 

Vaselini, gj; 30 1 M. 

or a sulphur ointment for several months after apparent 
cure. 

Trichophytosis barbae is treated along the same lines as 
when the scalp is the seat of the disease. The beard 
should not be shaved, but cut short with scissors. Here 
epilation is of more positive value, as the hairs over the 
nodules will come out easily. It is possible to abort the 
disease before it has implicated the hair by the application 
of a solution of five to ten grains of bichloride of mer- 
cury in alcohol. A ten per cent, solution of resorcin or 
an ointment of the same strength may accomplish the 
same end. After the disease has' got under full way, 



590 DISEASES OF THE SKIN. 

systematic epilation, daily shaving by the patient himself, 
and the thorough application of one of the parasiticide 
preparations mentioned in the preceding section will effect 
a cure. 

Trichophytosis unguium may be treated by producing a 
paronychia. This may be done by Pelizzari's l method 
of keeping green soap upon the nail under a rubber cot 
for a few days, until the nail is softened. Then equal 
parts of olive oil and pyrogallic acid are to be applied till 
the nail loosens, w T hen it is to be removed and the finger 
dressed with iodoform. Thin 2 recommends scraping the 
affected nails very thin, applying liquor potassse to soften 
them, and then dabbing on creosote, or acetic acid, or a 
solution of two to five grains of bichloride of mercury, in 
alcohol. Crocker speaks well of using Harrison's plan 
for treating ringworm of the scalp, which see. Solution 
No. 1 should be applied after scraping and kept on for 
fifteen minutes, covered with oiled silk ; then No. 2 ap- 
plied in the same way and kept on for twenty-four hours. 
These should be repeated till the cure is effected. If the 
skin should become tender or begin to peel, the solutions 
should be stopped, and one of hyposulphite of soda used 
until the skin heals. A ten per cent, salicylic acid plaster 
worn constantly over the nail is a good plan of treatment. 

Prognosis. All forms of ringworm, excepting that of 
the general surface of the body, are very obstinate, but 
persevering and intelligent treatment will cure them all. 
The most obstinate form is that of the scalp, and a speedy 
cure should never be promised. It must always be re- 
membered that as puberty is reached it tends to spontane- 
ous cure. 

Trichoptilosis. See Atrophia pilorum propria. 

Trichorrhexis Nodosa. See Atrophia pilorum propria. 

Trichoxerosis. See Atrophia pilorum propria. 

1 Giorn. Ital. d. Mai. Ven. e del Pelle, March, 1888. 

2 The Practitioner, May, 1887, et seq. 



TUBERCULOSIS VERRUCOSA CUTIS. -391 

Tubercula Miliaria. See Milium. 

Tubercula Sebacea. See Milium. 

Tubercule Anatomique. See Tuberculosis verrucosa 
cutis. 

Tuberculosis Cutis. Symptoms. This is a rare disease, 
having been met with by Chiari but five times in between 
3000 and 4000 post-mortems of those who had died of 
tuberculosis. It occurs almost exclusively about the 
mucous orifices — mouth, anus, vulva, and glans penis. 
Crocker describes the disease as follows : " The lesions 
consist of one or more discrete, shallow, not painful ulcers, 
which form apparently spontaneously, have an irregular, 
eroded, moderately infiltrated edge, and when the crusts, 
which soon cover them, are removed, show a reddish- 
yellow, granular surface, with a thin, scanty secretion. 
They never heal, but spread slowly and continuously, and 
may coalesce with neighboring ulcers, becoming serpigi- 
nous ; they may thus extend over an area of one or more 
square inches ; but, as a rule, they are small. When on 
mucous membranes, yellow miliary papules exist near 
them." They are due to local infection with the tubercle 
bacillus, and are a part of a general tuberculosis. Their 
diagnosis is difficult, though their nature may be suspected 
on account of the other and evident symptoms of the pri- 
mary disease. 

Treatment. Treatment is unavailing, though iodol, 
iodoform, or aristol may be applied. 

Tuberculosis Verrucosa Cutis. Synonyms : Verruca 
necrogenica ; Lupus verrucosus ; Scrofuloderma verruco- 
sum ; (Fr.) Lupus sclereux, ou 1. papillaire verruqueux ; 
Anatomical tubercle ; Post-mortem warts. 

These names have been given by different writers to 
what may be regarded as simply varying aspects of the 
disease described by Riehl and Paltauf l as tuberculosis 

1 Yierteljahr. f. Derm. u. Syph.,, 1886, xiii., 19. 



592 



DISEASES OF THE SKIN. 



verrucosa cutis. It is one of the rare skin diseases, but 
not so very infrequent as statistics would show. It was 
met with four times in 3726 cases in Professor Fox's 
service at the Vanclerbilt clinic in 1892. 

Symptoms. 1 The disease occurs usually in the form of 
a single round or oval patch. There may be several such 
patches. If two patches join, irregularly shaped patches, 
with scalloped border, may form, and perhaps become 
serpiginous. In size the single patches vary from that of 

Fig. 74. 




Tuberculosis verracosa cutis. (After Hyde.) 

a lentil up to that of a silver half-dollar. Around the 
patch is a narrow zone of erythema, of a bright-red, that 
disappears under pressure. Its surface is smooth, and 
often more shiny than the normal skin. Toward the next 
zone it is slightly elevated. Its follicular openings are 
preserved. 

Inside of this zone is a row of small, discrete, superfi- 
cial pustules, whose covers are so thin that they break 

iThe description here given is taken, for the most part, from the 
above-mentioned article by Riehl and Paltauf. 



TUBERCULOSIS VERRUCOSA CUTIS. 593 

easily, and we find only the crusts and scales left by them. 
The color of this zone is brown or livid red, and it can- 
not be pressed out entirely, showing that there is some 
infiltration of the skin. This zone is slightly raised, but 
the one to its inner side is markedly so. It has also an 
irregularly knobby surface, becoming distinctly warty 
toward the center of the growth, the warts being rounded 
or pointed. The nearer the center the warts are the 
larger they are, some of them being 5 to 7 mm. long. 
The whole surface of this zone is more or less scaly 
or crusted. The color is brownish- red. The warty 
growths are often close together with fissures between 
them, and little erosions and pustules. If the patch is 
pinched up between the fingers, little drops of pus may 
be made to well up from betAveen the papillae. The 
mouths of the follicles are destroyed. In some cases 
acute inflammation may occur, and the patch will swell 
up and become more angry-looking. 

After a time the patch begins to flatten in the middle 
by the disappearance of the warty growths, and at last 
becomes changed into a smooth or slightly scaling cica- 
trix, which is thin and soft, with a delicate sieve or net- 
like appearance. 

The patch is always freely movable upon the underly- 
ing parts, and usually gives rise to no subjective symp- 
toms. Sometimes pain is complained of on pressure. 
The growth is by the addition of new lesions on the pe- 
riphery of the old patch, and is usually very slow, and at 
intervals with pauses between. It is a chronic affection, 
showing no tendency to spontaneous recovery. 

Such is the typical disease and its course. In the de- 
scriptions of the different diseases named above will be 
found some deviations from the type, but they all agree 
in the main, and are probably all one and the same dis- 
ease. It is met with most often upon the backs of the 
hands and fingers, but may occur anywhere. 

Etiology. The cause of this form of tuberculosis is 
the inoculation of the skin with the tubercle bacillus, 
38 



594 DISEASES OF TEE SKIN. 

which has been found in sections taken from the patches. 
The disease is seen most frequently in men, and is spe- 
cially prevalent in butchers and those who have to do 
with animals such as hostlers and drovers. Dead-house 
attendants are also its victims not infrequently. Cases have 
been directly traced to inoculation with tubercular tissue. 

Diagnosis. Though allied to lupus, it differs from it 
by the entire absence of the characteristic lupus tubercles, 
and of the tendency to ulceration ; by the manner of heal- 
ing in the center by a scar in which no relapse takes 
place ; by its superficial situation in the skin ; by the 
purulent matter that can be squeezed out from between 
its papillse ; and by the relatively late time of life in 
which it appears. From syphilis it differs in its more 
chronic course ; in the absence of a wall of infiltration 
about it ; in its color ; and in showing no tendency to 
break down and ulcerate. 

Treatment. The growth may be curetted away, and 
the wound afterward treated with pyrogallol, as in lupus. 
Or it may be destroyed by the galvano-cautery, or by elec- 
trolysis. Or it may be covered with a twenty-five per 
cent, salicylic acid creosote plaster. Crocker advises the 
use of this plaster, to be followed with the fuming nitrate 
of mercury applied with a piece of wood. I have found 
the plaster sufficient in itself. Or it may be destroyed by 
any powerful caustic, but it must be destroyed entirely or 
it will crop out again. 

Prognosis. The disease is more easily curable than is 
lupus, and, as a rule, the growths are readily removed. 

Tumeurs Folliculeuses. See Molluscum sebaceum. 

Tumores Sebiparis. See Molluscum sebaceum. 

Tyloma. See Keratosis palmaris et plantaris. 

Tylosis. See Keratosis palmaris et plantaris. 

Tylosis Linguae. See Leucoplakia. 

Ulcers. Ulceration is a symptom common to many dis- 
eases such as lupus, syphilis, scrofulodermata, and other 



ULCERS. 595 

destructive processes. For these the reader is referred to 
the sections treating of the disease of which they form a 
part. I shall here deal briefly with those ulcers of the 
leg that form so large a part of every dermatological 
clinic, and that are usually called varicose ulcers. They 
are located most often over the anterior surface of the leg 
and on its lower half. They may be superficial or deep. 
They are irregular in shape with sloping or undermined 
edges, and with a more or less wide zone of redness and 
infiltration of the skin about them. Their bases may be 
covered with flabby granulations ; or smooth and glazed, 
with thin, scanty secretion ; or they may discharge a great 
deal of sero-purulent matter. Some of them bleed read- 
ily, some do not. There may be but one ulcer, or there 
may be several of them. One or both legs may be af- 
fected. The ulcers may be small, or so large as to encir- 
cle the leg and occupy more than half its length, and they 
may attain this size either by gradual extension of them- 
selves, or by the junction of several ulcers. They begin not 
infrequently as a number of small shelving ulcers on a red 
and densely infiltrated base. These enlarge rapidly and 
form a large ulcer. The patient complains of more or 
less spontaneous pain, and the ulcers are often very tender. 
The foot and leg are sometimes greatly swollen and feel 
brawny. It will be noted that the foot and leg are marked 
with dilated veins, and varicosities can be felt sometimes 
like whip-cords under the skin. The deep veins are gen- 
erally swollen at the same time, though they cannot be 
felt so readily. Usually both legs are affected. 

Etiology. These ulcers are predisposed to by stand- 
ing for hours at a time, and it is standing in one position 
that is particularly obnoxious. It is therefore in car- 
drivers, blacksmiths, cooks, and those following similar 
occupations that ulcerations are prone to occur. A loaded 
condition of the portal circulation and constipated bowels 
also favor varicosities and the occurrence of ulceration. 
On account of the chronic, congested condition of the leg, 
some slight traumatism that in the normal state would 



596 DISEASES OF THE SKIN. 

produce a hardly appreciable damage will be followed by 
a breaking down of the tissues and an ulcer. 

Diagnosis. It is most important to diagnose a vari- 
cose ulcer from one due to syphilis, as they require dif- 
erent treatment, and have a different prognosis. The 
syphilitic ulcer is usually located upon the upper half of 
the leg, and toward its posterior surface, or about the knee. 
It has an infiltrated border, but by no means as broad a 
one as the varicose ulcer. It lacks the marked inflamma- 
tory symptoms of the varicose ulcer, and is " punched-out 
looking' 7 with perpendicular edges. It is round, or, if 
formed by the coalition of several softened tubercles, it 
will have a scalloped edge, indicating its origin from sev- 
eral distinct lesions. As a rule, it is quite painless, and 
there are several ulcers on one leg, the other being free. 

Treatment. If we can confine our patient absolutely 
to bed, and keep the leg snugly and evenly bandaged, the 
ulcers will heal under simple dressings. This we cannot 
do with most of our cases. Bandaging the leg from the 
toes to the knee is an essential in their successful manage- 
ment, an ordinary roller-bandage being used as long as 
any greasy applications are made. In ulcers connected 
with varicose veins, after acute symptoms have subsided, 
bandaging from the toes to the knee with a rubber band- 
age is excellent. So too in all ulcers is the continuous 
bath with warm water, or by means of cloths wrung out 
of hot water, frequently renewed and covered with oiled 
silk. 

One of the oldest and best treatments for ulcers is to 
touch them daily with balsam of Peru and cover them 
with oxide of zinc ointment, or, better, with Lassar's 
paste. Dry dressings for the ulcer are preferable to 
greasy applications, and for this we may use iodoform, 
iodol, aristol, subnitrate or subiodide of bismuth, or der- 
matol, or any of the later remedies. If there is any eczema 
or dermatitis about the ulcer, it is requisite to cover the 
powder and the whole patch with some mild or stimulat- 
ing ointment according to the state of the skin. In this 



ULERYTHEMA. 597 

case the ulcer must be dressed once or twice a day. If 
there is not much dermatitis, we can dispense with the 
ointment and do the leg up antiseptically and leave it for 
several days. Applications of nitrate of silver may be 
used to stimulate an atonic ulcer or to smooth down ex- 
uberant granulations. Strapping with adhesive plaster is 
another excellent means in ulcers upon not very much 
inflamed bases. Skin-grafting, according to Thiersch's 
method, is the most prompt and sometimes the only way 
to cause large ulcers to heal. For further surgical treat- 
ment of ulcers text-books on surgery must be consulted. 

Ulcer, Perforating 1 , of Foot. See Perforating ulcer of 
foot. 

Ulcer, Tropical Phagedenic. This is an ulcer second- 
ary to a lesion of the skin that occurs in the tropics, and 
is marked by rapid extension and gangrenous destruction 
of tissues. It may be mild or malignant in its course. 
The latter eats deeply, even involving the bones. 

Ulcus Rodens. See Epithelioma. 

Ulcus Grave. See Fungous foot of India. 

Ulerythema (LPl-e^-P-the'-ma 3 ). This is the name pro- 
posed by Unna for those diseases in which there is a more 
or less persistent erythema upon which follows cicatriza- 
tion by a process of absorption of inflammatory infiltra- 
tion, and without ulceration. Under this heading comes 
lupus erythematosus. Ulerythema syeosiforme 1 and ulery- 
thema ophryogenes 2 are two other varieties of this form of 
disease. They bear a resemblance to the " folliculitis de- 
calvans" of the French. They both affect hairy regions, 
the first having a predilection for the beard, and the second 
for the eyebrows. In their course they present symptoms 
somewhat like sycosis, but differ from that disease in caus- 
ing permanent bald patches, and the destruction of the skin 
so as to form cicatrices. 

1 Monatshefte f. prakt. Dermat., 1,889, ix., No. 3. 
2 Ibid., No. 5. 



598 DISEASES OF THE SKIN. 

Ulerythema Acneiforme is the name given by Unna * to 
a purely local, probably parasitic, disease of the skin 
which is limited to the neighborhood of individual hair 
follicles. It begins as an inflammatory erythema, which, 
after persisting for some time, leads either to the forma- 
tion of a well-marked cornification of the cuticle and 
comedones, or to cicatricial atrophy. 

It differs from acne by beginning on the middle of the 
cheek and margin of the auricle ; by extending to the 
hairy scalp ; by being primarily an inflammatory ery- 
thema; by an absence of suppuration, and by atrophy 
occurring without suppuration. It differs from acne vari- 
oliformis by complete absence of necrosis, suppuration, and 
ulceration ; by prominence of comedones ; and by having 
no resemblance to variola in its scar. 

Uridrosis (U 2 r-i 2 d-ro'-si 2 s). Synonyms : Sudor urinosis. 
By this is meant the excretion by the sweat pores of sweat 
loaded with the constituents of the urine, specially urea. 
The sweat then often has a urinary odor, and deposits 
crystals of urates upon the skin. It is always a compli- 
cation of some grave general disease. 

Urticaria (IPr-tP-ka'-rP-a 3 ). Synonyms : Cnidosis ; 
(Fr.) Urticaire ; (Ger.) Nesselsuch, Nesselauschlag, Por- 
cellanfriesel ; (Eng.) Nettle-rash, Hives. 

An acute or chronic disease of the skin characterized by 
the appearance of wheals. This usually trivial affection, 
so common as to be a matter of every-day occurrence, at 
times may assume grave symptoms, or entirely nonplus 
us by its persistency. It may run an acute or chronic 
course. 

Symptoms. The vast majority of cases run an acute 
course. The characteristic feature of the disease is the 
appearance of wheals — that is firm, flat, circumscribed ele- 
vations of the skin which are at first pink, and then white. 
They may remain pink. They may be round, oval, annu- 
lar, or elongated, and are always surrounded by a red 
1 Internat. Atlas of Kare Skin Diseases, No. 1. 



URTICARIA. 599 

areola. They vary in size, sometimes being no larger than 
the head of a pin, and sometimes of the diameter of an 
inch. They show no tendency to group, bnt are irregu- 
larly disseminated over the whole body. Though they 
are not symmetrical in distribution, both sides of the body 
are affected at the same time, and they show some prefer- 
ence for the extensor surfaces of the arms and legs. They 
itch, burn, and tingle, and are always scratched. They 
are ephemeral, each lesion lasting but a short time — from 
a few minutes to a day. Exceptionally some wheals will 
last several days. New lesions crop out as- old lesions 
fade, and thus the eruption is continued. The mucous 
membranes are often affected at the same time with the 
skin ; and if the pharynx is attacked there may be suffo- 
cative symptoms. The duration of the disease as com- 
monly met with is but a few days, and not infrequently 
the wheals may be entirely absent during the day, to break 
out again at night. Very often when the patient is seen 
by the physician, he can find nothing but scratched 
papules. But the patient will tell him that when he is 
undressing, or is warm in bed, the itching becomes un- 
bearable, and lumps looking like mosquito-bites break 
out upon him. The skin of a patient with urticaria is 
very irritable, so that a sharp tap upon it or drawing the 
nail across it will produce a wheal. 

The outbreak of the disease may be sudden without con- 
stitutional disturbance, or there may be some burning and 
tingling of the skin before its appearance. Or there may 
be some febrile movement, and some evident disturbance 
of the digestion such as vomiting or dyspeptic symptoms. 
When the disease is cured the lesions disappear without 
desquamation, and leave no trace of themselves. Such is 
the acute form. 

Chronic urticaria differs from the acute form mainly in 
its duration. Instead of recovery taking place in a few 
days or weeks, its course is one of months and years. 
Sometimes the outbreaks of the eruption show marked 
periodicity, coming out at stated intervals after pauses of 



600 DISEASES OF THE SKIN. 

complete immunity. The eruption is generally not so ex- 
tensive in the chronic as in the acute form. If the itch- 
ing has been very severe and the scratching proportionally 
excessive, the skin may become pigmented, as in other 
chronic pruriginous diseases. 

The wheals assume different appearances in different 
cases, and different adjectives are used to express the 
varying pictures. It is not necessary to burden the mind 
with these, though they are convenient for descriptive 
purposes. Thus we have urticaria tuber osa seu gigans, 
where the lesions are unusually large ; urticaria bullosa, 
where the wheals are surmounted by bulla?; urticaria 
hemorrhagica, where hemorrhage into the wheals occurs ; 
urticaria oeclematosa, probably the same as acute circum- 
scribed oedema, or acute angioneurotic oedema, where the 
wheal occurs in locations in which the subcutaneous tis- 
sues are lax, as about the eye, nearly closing it, or on the 
tongue, causing it to swell enormously and threaten suffo- 
cation ; urticaria papulosa, or lichen urticatus, where the 
wheals are small, a form common about the buttocks of 
children. 

Urticaria factitia is the name used to express the fact 
that, on account of the irritability of the skin, a wheal may 
readily be excited by local irritation. Urticaria perstans 
simply refers to the persistent character of the single 
lesion. Urticaria maculosa is the name proposed by 
Fournier for that form in which the wheal remains red. 

Etiology. The causes of the disease are more numer- 
ous than the forms it may assume. Most of the acute 
and many of the chronic cases are dependent upon irritat- 
ing ingesta, such as shell-fish, strawberries, cheese, pickles, 
mushrooms, pork, sausages, even mutton in some, and 
almost anything in other people, it being largely a matter 
of idiosyncrasy ; medicinal substances, such as quinine, 
cubebs, copaiba, salicylic acid, opium, and other drugs. 
The rupture of hydatid cysts has been followed by urti- 
caria. Dyspepsia in its various forms, and constipation, 
are common factors, especially in chronic urticaria, as are 



VRT1CAB1A. 601 

intestinal worms in children. So also at times may be 
disorders of the liver, uterus, and ovaries. Some very 
severe cases occur during pregnancy. Gout, rheumatism, 
malaria, and functional or organic diseases of the nervous 
system will be found at the bottom of many cases of 
chronic urticaria. 

Xot only do we have internal causes producing the dis- 
ease, but also external causes, such as contact with the 
jelly-fish ; crawling of caterpillars ; the action of cold, 
or sudden changes of temperature ; the galvanic current ; 
and bites of insects. Urticaria is a common accompani- 
ment of scabies and pediculosis. 

Pathology. Urticaria is due to a vasomotor disturb- 
ance. At first there occurs a spasmodic contraction of 
the vessels of a circumscribed area of the skin, which is 
followed by paralytic dilatation of the vessels and retarda- 
tion of the circulation. Serous exudation ensues, forming 
the wheal, which at first is pink, and then becomes white, 
on account of the pressure of the fluid forcing out the 
blood from, the central parts of the wheal. When the 
paresis ceases, the serous exudation is absorbed and the 
part returns to its normal condition. T. C. Gilchrist 1 
does n )t believe in the vasomotor theory of the disease. 
He thinks that it is an inflammation of the skin due to 
the escape of some toxin from the blood into the derma. 

Diagxosls. The occurrence of wheals is pathogno- 
monic of urticaria, as they occur in no other disease. 
When they are present there is no difficulty in diagnosis. 
When they are not present and we find only scratch-marks 
we have to decide whether we have to do with urticaria or 
eczema, scabies, pediculosis, or dermatitis herpetiformis. 
Eczema differs from urticaria in the tendency its lesions 
have of running together and forming patches. It never 
could be so generally distributed without presenting some 
characteristic patches. Scabies shows scratch-marks on 
the hands and feet, between the fingers and toes, in the 
axillae, about the umbilicus, and on the breasts of women 
1 Jour. Amer. Med. Assn., 1896, xxvii., 1222. 



602 DISEASES OF THE SKIN. 

and the penis of the male. The cuniculi may be found 
in most cases. Pediculosis shows long parallel scratch- 
marks over the back, between the shoulders, along the 
outside and inside of the limbs where the seams of the 
clothing come, and about the waist. Dermatitis herpeti- 
formis presents grouped lesions, which usually are vesi- 
cles, but may be papules. Erythema of papular or tuber- 
cular variety may resemble urticaria, but it is a markedly 
symmetrical disease, and burns rather than itches. 

Treatment. In acute urticaria the administration of 
a prompt cathartic or saline laxative will usually cure the 
disease if due to some irritating ingesta. Emetics might 
be useful, if we see the case before stomachic digestion is 
ended, but in most cases we are not called in until too late 
for them to be of service. Saline laxatives, mineral acids, 
rhubarb and soda, salol, resorcin, or other intestinal dis- 
infectants are of service in the more chronic cases. Of 
course, if the eruption is due to the ingestion of drugs, 
they must be stopped. 

In chronic cases, besides medicinal treatment we must 
regulate the diet, studying each case for itself. It is often 
well to put the patient on a strictly milk diet for a few 
days, and then add other articles with care. Alcoholics 
in all forms, and especially beer or other malt liquors, 
should be prohibited. If the gouty or rheumatic diathesis 
is at the foundation of the trouble, it must be combated. 
If the outbreak shows marked periodicity, sulphate of 
quinine may do good. Salicylate of soda sometimes does 
good service even when there is no evident rheumatic 
tendency. In fact, we must endeavor in every way to 
get our patient into a normal state of health. The most 
difficult class of cases are those in which a neurosis alone 
seems to be the cause. Then belladonna, atropia, arsenic, 
the bromides, antipyrine, phenacetin, and galvanism may 
be tried. Pilocarpine, wine of antimony, colchicum, 
ergot are also commended. In very obstinate cases the 
patient should be sent away from home and relieved from 
all business cares. 



URTICARIA PIGMENTOSA. 603 

Local treatment is of great service in allaying the itch- 
ing, but it will not cure the disease. The parts may be 
sponged with alkaline lotions, such as a teaspoonful of 
baking-soda to a hand-basinful of water. Sometimes more 
relief is obtained by an acid solution, such as vinegar, 
pure or with water. Carbolic acid in vaseline, or alcohol 
and water, is sometimes very efficacious. In vaseline, 10 
per cent, strength is sufficient ; in lotion-form we may 
use, to the adult skin, one to two drachms to the ounce, 
directing the patient to dab and not rub it on the skin. 
Hardaway prefers using the acid in a spray, two to four 
drachms to the pint, with one ounce of glycerine. To 
each atomizerful ten drops of oil of peppermint may be 
added to increase its antipruritic qualities. Menthol, 1 to 
10 per cent, in alcohol or almond oil, is said to be effica- 
cious. Crocker speaks highly of liquor carb. detergens, 
5j to 5iv ; terebene, 5iv to Siv ; and equal parts of sanitas 
and water. Salicylic acid, twenty grains to the ounce of 
castor oil, is good, but disagreeable. Camphor and chloral 
hydrate, each from half to one drachm, rubbed together 
and added to one ounce of starch or ungt. simplex, is an- 
other good antipruritic. Chloroform dabbed or sprayed 
on renders prompt relief. Baths are sometimes of use. 
Having the patient take a warm bath containing either 
two to six pounds of bran, or a quarter to half a pound 
of bicarbonate of soda, or an ounce of nitro-muriatic acid, 
just before going to bed ; then drying the skin by wrap- 
ping in a warm sheet and patting the skin dry ; then 
smearing the skin with a film of vaseline and dredging 
over this cornstarch powder, will often give him a good 
night's rest. 

Peogxosis. The vast majority of cases of urticaria 
recover in a few hours or days. The chronic cases often 
are most obstinate, but unless some severe nerve lesion is 
at the bottom of the case, they can be cured by patient 
and persevering effort. 

Urticaria Pigmentosa. Synonyni : Xanthelasmoidea. 



604 DISEASES OF THE SKEX. 

Symptoms. This is not an ordinary urticaria, that, on 
account of its chronic course and the scratching to which 
it has been subjected, leaves more or less pigmentation of 
the skin. Such a condition of things is not infrequently 
seen. Urticaria pigmentosa begins within the first six 
months of life by an eruption of wheals or tubercles, which 
at first are about the size of a split pea, and of a brownish 
or yellowish-red color, with a pink areola. Later, they 
may increase in size, or several may coalesce to form a 
large one, and assume a yellow or buff color. These 
wheals appear in crops, and run a very chronic course, 
each one persisting for weeks or months. They then 
shrink, become softened, and disappear, leaving brownish 
pigmentation. As the course is chronic, we will find on 
the patient wheals or tubercles of red or yellow color, of 
various sizes, some hard and tense, some soft and wrinkled, 
and brown stains of the skin. Ordinary urticarial evanes- 
cent wheals will sometimes be found, and rubbing of the 
apparently stationary tubercles will cause some of them 
to enlarge. The wheals are most often located on the 
trunk and neck ; then on the limbs, face, and head ; but 
they may appear on any part of the body surface as well 
as on the mucous membranes of the mouth and pharynx. 
Itching may or may not be present. After a number of 
years the wheals will no longer come out, and recovery is 
generally complete at about the age of puberty, though 
the disease may last much longer than that. Morrow 1 
has reported one case of over twenty years' duration. 
The majority of the cases, according to Crocker, occur in 
boys. We know no cause for the disease, and thus far 
treatment has been in vain. 

Vaccinal Eruptions. The eruptions that accompany or 
follow vaccination may be local, starting from the point of 
inoculation ; or general, and due to the absorption of the 
virus, which in some subjects acts as do medicinal sub- 
stances in other people. The majority of them are due 

1 Jour. Cutan. and Gen.-Urin. Dis., 1895, xiii., 445. 



VARIOLA. 605 

not to any bad quality of the virus, but either to some 
accidental infection, or to idiosyncrasy. Sometimes an 
ulcer will form at the site of the vaccination ; or starting 
from this point we may have a dermatitis, cellulitis, lym- 
phangitis, erysipelas, abscesses, or furuncles. At times 
exuberant granulations, or what is called an infective 
granuloma, may develop upon the seat of the vaccination. 
An outbreak of impetigo contagiosa may originate from 
inoculation, the pus of the sore becoming transferred to 
other parts by the finger-nails ; or an eczema or psoriasis 
may be set up by the irritation of the sore, just as they 
may follow other affections of the skin. 

General eruptions usually appear, according to Harda- 
way, after the ninth or tenth day of vaccinia, and assume 
an erythematous, papular, or papulo-vesicular character. 
The roseola vaccina of Hebra is an erythematous eruption 
of macular character, commencing usually upon the arms, 
and sometimes spreading over the whole body. It is ac- 
companied in some cases with slight rise of temperature 
for a few hours. It disappears and leaves no trace. 

We may also encounter erythema multiforme and urti- 
caria complicating vaccination. It is possible that a bul- 
lous eruption may occur, but this is very rare. Syphilis 
also may be inoculated in arm-to-arm vaccination. Gan- 
grene may occur in the sore and other accidents. All of 
these are rare. 

Varicella (Ya 2 r-i 2 -se 2 l'-la 3 ), or Chicken-pox, is an erup- 
tive fever of mild grade, with an incubative period of two 
weeks. It is characterized by an outbreak of a greater or 
less number of red papules and clear vesicles, of pinhead- 
to pea-size, and varying shape, that come out in crops. A 
long vesicle is very characteristic of this eruption. There 
is usually only slight constitutional disturbance. The 
mucous membranes may be involved. 

Varicella Gangrenosa. See Dermatitis gangrenosa in- 
fantum. 

Variola (Ya 2 r-i'-o 2 l-a 3 ), or Smallpox, is an acute conta- 



606 DISEASES OF THE SKIN. 

gious fever, with an incubative period of about two weeks. 
It is characterized by very severe prodromal symptoms, 
such as headache and intense pain in the back and legs, 
and the appearance, usually on the third day, of an erup- 
tion of minute red spots that soon change into small, 
round, hard, shotty papules. The eruption is first seen 
on the face about the mouth and on the neck and wrists. 
In about twenty-four hours after its first appearance vesi- 
cles form upon the papules, and attain their full develop- 
ment by about their fifth day. They then are umbilicated, 
are located upon a hard base, and have a well-marked 
areola. Now they change into pustules, and a well- 
marked secondary fever attends the change. After about 
four or five days the pustules dry up into crusts, and after- 
ward these fall, leaving pitted cicatrices in many places. 
The mucous membranes may be involved. In varioloid, 
modified smallpox, the constitutional symptoms as well as 
the eruption are of much milder grade. 

Diagnosis. Variola bears a resemblance to the pus- 
tular syphilide ; for the differential diagnosis, see the 
" pustular syphilide." Acne and pustular eczema both 
have lesions resembling those of variola, but are limited 
to certain regions, and are not general eruptions. Vari- 
cella and papular erythema have been mistaken for 
variola. In its earlier stages the diagnosis of variola is 
very difficult. In pronounced cases, on the other hand, 
the diagnosis is easy. 

Varus. See Acne. 

Vegetation dermique. See Verruca. 

Vegetations. See Verruca. 

Venereal Wart. See Verruca. 



Verbrennung. See Dermatitis ambustionis. 

Verruca (Ve 2 r-ru 2/ -ka 3 ). Synonyms : (Fr.) Verrue ; 
rer.) Warze ; Warts. 

These exceedingly common papillary outgrowths assume 



VERRUCA. 607 

various appearances, to which descriptive names have been 
given. Thus we have verruca vulgaris, or the wart so 
often seen on the hands of children and young people. 
They vary in size from that of a hemp-seed to that of a 
split pea, or larger where two or more become aggregated. 
They are sessile, hard, conical, with flattened tops. They 
may be smooth, or uneven, showing their papillary for- 
mation. They may be of the color of the skin, or some 
shade of yellow, brown, black, or green. There may be a 
number of them, and they may be isolated or aggregated. 
They may occur elsewhere than on the hands. Verruca 
digitata is applied to a wart in which the papillse are 
separated distinctly from each other. They occur in 
groups, and are often seen on the scalp. Verruca filiform is 
is a w T art in which the papillae are not only distinct but 
fine, almost thread-like. Each papillary outgrowth stands 
by itself. They are soft to the touch, and occur on the 
face, eyelids, and neck. Verruca plana are flat warts, but 
slightly elevated, and varying in size from a pin's head to 
a half-inch in diameter. They sometimes occur in large 
numbers. In young people they occur upon the face and 
backs of the hands, and may or may not be pigmented. 
In old people they occur on the trunk and arms and are 
pigmented. In them they are called verruca senilis, or 
seborrheal warts. Verruca acuminata, also called con- 
dyloma acuminata, vegetations dermiques, spitzen ivarzen, and 
venereal or moist warts, are met with in the anal and geni- 
tal regions of both sexes, as also in the axilla?, under the 
hanging breasts, in the umbilicus, and between the toes. 
They are vascular, sessile or pedunculated, and composed 
of a great number of closely aggregated projections of 
various shapes. On exposed situations they are dry and 
of the color of the skin ; while in locations that are moist 
— that is, between the skin-folds — they are covered with 
a whitish puriform secretion, and, unless kept very clean, 
they emit an offensive odor. They sometimes attain to an 
immense size. 

Etiology. AVe do not know the cause of warts. 



608 DISEASES OF THE SKIN. 

They are regarded by some as contagious, and parasites 
have been isolated and declared to be the morbific agents. 
They have been produced by inoculation. They occur 
more frequently in the young than in the old, and may 
be congenital. Verruca acuminata are traceable to irri- 
tating discharges, but not by any means always to a 
gonorrhoea. They are undoubtedly contagious. 

Treatment. The treatment of most all warts is 
prompt and efficient by means of the curette, scraping 
them off while the skin is slightly stretched. If there is 
any doubt about their returning, their bases may be 
touched with iodine or nitric acid. Generally simple 
scraping is sufficient. Electrolysis may be used. The 
digitate and filiform warts may be snipped off with the 
scissors. If operative interference is refused, the warts 
may be removed by painting with tincture of iodine ; or 
a saturated solution of salicylic acid ; or a 20 per cent, 
solution of resorcin ; tincture of thuja ; or nitric or gla- 
cial acetic acid. In the country children's warts are re- 
movable in some cases by the application of the juice of 
the common milk-weed. Acuminate warts may be re- 
moved by keeping them clean and dry, and painting them 
with liq. plumbi subacetatis, or a solution of the perchlo- 
ride or persulphate of iron ; or dusting them with salicylic 
acid and starch, or boric acid. Chromic acid is a power- 
ful caustic. Caustic potash is not a safe one to use, unless 
care is had to limit its action by a ring of wax about the 
wart. The galvano-cautery may also be employed. 

It is said that warts may be removed by internal treat- 
ment. Sulphate of magnesia, two or three grains to a 
child and half a drachm to an adult, three times a day, is 
one remedy. Besnier has tried this method in a number 
of cases with absolute unsuccess. Tincture of thuja oc- 
cidentals is said to be efficacious. Crocker thinks he has 
seen cures effected with full doses of nitromuriatic acid, 
while others advocate arsenic. 

Warts very often disappear of themselves, and no one 
has ever seen them fall. 



XANTHOMA. 609 

Verruca Necrogenica. See Tuberculosis verrucosa cutis. 

Verrue. See Verruca. 

Verrue Telangiectasique. See Angiokeratoma. 

Verrugas, Endemic. See Yaws. 

Vibices. See Purpura. 

Vitiligo. See Leucoderma. 

Vitiligo Capitis. See Alopecia Areata. 

Vitiligoidea. See Leucoderma. 

Wart. See Verruca. 

Warze. See Verruca. 

Warzenkrebs. See Carcinoma. 

Warzenmal. See Xsevus verrucosus. 

Washleather Skin is that condition of the skin in which 
certain metals, specially silver, mark it with a black line. 
It occurs, as a rule, in patients suffering from diseases 
which directly or indirectly affect either the trophic or 
the sensory nerves, such as renal disease, phthisis, erysip- 
elas, and hemiplegia. Is sometimes precedes the occur- 
rence of bed-sores. 

Weichselzopf. See Plica. 

Wen. See Sebaceous cyst. 

Whelk. See Acne. 

Xanthelasma. See Xanthoma. 

Xanthoma (Zamth-orn'-a 3 ). Synonyms : Xanthelasma ; 
Vitiligoidea ; Molluscum cholesterique ; Fibroma lipoma- 
todes. 

A peculiar disease of the skin characterized by the ap- 
pearance of discrete patches, or tubercles, of chamois or 
lemon-yellow color. 

Symptoms. Xanthoma may assume one of two forms : 
39 



610 DISEASES OF THE SKIN. 

Xanthoma planum, or Xanthoma tuberosum or tubercu- 
latum. In the former we meet with flat, chamois-leather, 
or lemon-yellow plates that are either slightly raised above 
the level of the skin, or not at all raised. They vary in 
size from an eighth of an inch to an inch in their long 
diameter, feel soft and smooth to the touch, and when 
pinched between the fingers no infiltration of the skin is 
perceptible. They are irregular in shape, tending to form 
elongated figures. When in patches they feel almost vel- 
vety, and when examined with a lens they are seen to con- 
sist of an aggregation of small granules, many of which 
have a central pinkish punctum. 

Xanthoma tuberosum exhibits lesions of the same color 
as does the plain variety, or they may be of reddish- 
yellow, but they are raised above the skin and may attain 
to a large size. They are soft, smooth, round, or oval, 
with telangiectases over them when small. When large, 
they are firmer and more irregular in shape, being made 
up by aggregation of a number of smaller tubercles. 
Xanthoma multiplex is the name applied to cases in which 
both varieties are present. In all forms, unless there is 
jaundice, the skin between and about the lesions is normal 
in color. Most cases give rise to no subjective symptoms, 
but there may be some itching or burning. If the disease 
occur upon the palms or knees, it may cause discomfort or 
even pain on kneeling or handling objects. 

The favorite site of xanthoma planum is in the upper 
eyelid, where they are not infrequently seen. There they 
commence at the inner canthus, most often of the left eye, 
and spread in a semicircle about the eye, while shortly 
afterward a similar growth begins on the right upper eye- 
lid. Next in point of frequency to the eyelids, they occur 
upon the flexures and mucous membranes. Xanthoma 
tuberosum is most frequently seen upon the knees, elbows, 
knuckles, and other points of pressure, the trunk being 
not so much affected. Symmetry is generally observed. 
Xanthoma multiplex is often very widely distributed. 
Sometimes the lesions run in streaks, or, as in Hardaway's 



XANTHOMA. 611 

case, 1 are arranged like a zoster. The following case re- 
ported by me 2 is one of the most extensive on record : 3 

Michael M., aged five years, was admitted to my service 
at the Randall's Island Hospital in May, 1890. From 
the child's sister I have been able to gather the following 
imperfect history : The eruption appeared when the child 
was three months old, without any antecedent disease, and 
came out all over the body at the same time. It is thought 
that no new lesions have appeared since then ; that there 
has been change in the size of the lesions, and that some of 
them have disappeared. The boy is said to have always 
been well, to have played about like other boys, and never 
to have been jaundiced. 

Examination of the boy reveals a very extraordinary 
condition of affairs ; the whole body of the boy is occu- 
pied by a disseminated efflorescence, no part being spared 
except the hands, feet, and scalp. The lesions are about 
the size of a split pea, or a little smaller, are soft to the 
touch, and have a central depression. Upon the face, 
trunk, shoulders, and lower part of the legs they are dis- 
crete, and scattered about without any particular arrange- 
ment. Upon the extremities the lesions are crowded into 
patches of various sizes and shapes, with normal skin be- 
tween them. Even in the patches the lesions are distinct. 
They touch each other but do not coalesce. The distribu- 
tion of the lesions and of the patches is quite symmet- 
rical. The color varies from a lemon-yellow in the dis- 
crete lesions on the shoulders to an orange-yellow in the 
patches. About the joints the color is reddish-brown. 

In the right eyelid are well-marked, typical xanthoma- 
tous patches of chamois-leather color. The lower lid is 
occupied by one continuous patch, running from the inner 
to the outer canthus. On the upper lid there is a small 
tumor. The left lid is but very slightly affected. Upon 

J St. Louis Courier of Med., October, 1884. 

2 Jour. Cutan. and Gen.-Urin. Dis.,,1890, viii., 241. 

3 See frontispiece for illustration. 



612 DISEASES OF THE SKIN. 

the back of the neck and the upper part of the back are 
a number of light-brown pigmentary spots, which his sis- 
ter says are the remains of some lesions that have disap- 
peared. Scattered about the trunk are a number of de- 
pressed scars, apparently the remains of a recent varicella. 
The boy is very thin, of blonde type, and the skin is 
pale. Apart from this there is nothing abnormal. His 
appetite is good, his digestion is in fine condition, and his 
urine contains neither albumin nor sugar. Upon the left 
buttock there is one vascular nsevus. 

The skin in Xanthoma is not alone affected. Xantho- 
matous bodies are found in the liver, mucous membranes, 
and tendons. The disease is progressive for a time, and 
then may remain stationary for years, or may undergo 
spontaneous resolution. 

Etiology. Xanthoma occurs much more frequently 
in adults than in children, and that form that occurs in 
the eyelids is much more common in women than in men. 
Several cases may be seen in the same family, and the 
disease is sometimes hereditary. But we really do not 
know as yet what is the cause of the disease, though va- 
rious theories have been advanced. Hepatic diseases ; 
diabetes ; diathetic conditions of various kinds ; migraine ; 
embryonic cells left in the skin ; each have been found in 
connection with one or many cases. Hardaway may not 
be wrong in his idea that it is a diathetic disease, and that 
when it occurs with jaundice it is because the same tuber- 
cles have been deposited in the liver as in the skin, and 
the jaundice is secondary to them. 

Pathology. It is a connective-tissue new growth 
containing an abundance of fat. Between the connective- 
tissue bundles the so-called " xanthoma cells " are found. 
The color of the lesions is due to fat-globules. (Heitz- 
mann.) 

Diagnosis. The diagnosis of this unique disease is 
made by the occurrence of chamois-leather-colored soft 
plates or tubercles, such as occur in no other disease. 



XANTHOMA DIABETICORUM. 613 

Milium may bear some slight resemblance to xanthoma, 
but it is hard and firm, not soft and velvety, and white, 
not yellow. It is easily squeezed out after a prick through 
the skin over it, an impossibility in xanthoma. 

Treatment. In the way of treatment we have no 
sure resource save the knife and electrolysis. The latter 
is the more preferable of the two. In so general a case 
as mine, neither plan would be applicable. Besnier l re- 
ports good results from the administration of phosphorus 
in cod-liver oil, giving one milligramme per day, and in- 
creasing the dose each day by a quarter of a milligramme 
until three milligrammes are taken. After fifteen days 
this is stopped and turpentine is given. Stern 2 tried 
this plan without success, but succeeded in removing 
patches of the disease from the eyelids by the use of a 
ten per cent, solution of corrosive sublimate in collodion. 
Shepherd, of Montreal, saw one case recover after an 
operation for biliary calculi. 

Xanthoma Diabeticorum. Besides the xanthoma just 
described there is another form which is regarded as a dis- 
tinct affection, and called Xanthoma diabeticorum. 

Symptoms. It is an exceedingly rare disease, which 
differs from ordinary xanthoma in its more sudden devel- 
opment ; in disappearing sooner or later, perhaps to recur ; 
by the hardness of its lesions, which are never macular ; 
by the frequent absence of a yellow color ; by the pres- 
ence of a certain amount of inflammation ; by absence of 
jaundice, and presence of diabetes mellitus ; by its more 
pruriginous character : by avoiding the eyelids ; and by 
having its lesions about the mouths of the hair follicles. 
In fact it resembles ordinary xanthoma mostly in its loca- 
tion upon the elbows, knees, aud other points of pressure, 
and in the general configuration of the lesions. In it we 
have conical papules with yellowish apices and pinkish 
red bases. The treatment should be directed to the dia- 

1 Jour, de Med. et de Chir., April, 1886. 

2 Berlin, klin. Woch., 1888, xxv., 393. 



614 DISEASES OF THE SKIN. 

betes, which is at the foundation of the disease, and to the 
allaying of the itching. 

Xeroderma. See Ichthyosis. 

Xeroderma Pigmentosum. See Atrophoderma pigmen- 
tosum. 

Yaws 1 (Ya 4 z). Synonyms : Framboesia ; Pian ; Par- 
angi ; Verruga. 

This is a disease that occurs only in tropical countries. 
The stage of incubation lasts two to eight weeks and is 
without special symptoms. The stage of invasion, with 
more or less well-marked fever, which abates before the 
eruption appears, lasts one or two weeks. The eruption is 
preceded by enlargement and tenderness of the lymphatic 
glands, and consists of pinhead- to lentil-sized, slightly 
elevated papules on a broad base. The papules enlarge, 
the epidermis splits and curls off from their centers, and 
exposes a yellowish point which develops into a flat, moist, 
red, or pink tumor, looking not unlike a raspberry. These 
tumors range in size from a split pea to a nut, are round 
or oval, discrete, or coalesced into large irregular masses. 
The surface of the tumor is covered with a thin, yellow- 
ish, foul-smelling discharge, that dries into a crust, which 
may ultimately form rupia-like crusts. In the mouth and 
in moist situations no crusts form, and the tumors will re- 
semble mucous patches. They reach their full develop- 
ment in from two to four weeks, remain stationary for 
months, and then dry up and fall off, leaving a stain on 
the skin that eventually disappears. They may break 
down and ulcerate, involving both the adjacent soft parts 
and the bones. The tumors are not tender. The disease 
tends to recovery, but is subject to relapses. It is conta- 
gious, and one attack is protective to a certain extent. 
Death occurs in bad cases. There is a probability that 
the disease is syphilis modified by climatic and racial 
influences. 

1 This account is condensed from Crocker. 



ZOSTER. 615 

Treatment. The treatment is the same as in syphilis, 
that is, by mercury and iodide of potassium. Locally, 
disinfectant and mercurial applications should be used. 

Zaraath. See Lepra. 

Zona. See Zoster. 

Zoster (Zo 2 st'-u 5 r). Synonyms : Zona ; Herpes zoster ; 
Ignis sacer ; (Ger.) Feuergurtel, Gurtelkrankheit ; Shin- 
gles. 

An acute disease of the skin characterized by a unilat- 
eral eruption of groups of vesicles upon reddened bases 
scattered along the course of certain nerves. 

Symptoms. Zoster, like psoriasis, presents such marked 
lesions that once seen it is readily recognized when seen 
again. It occurs in the form of groups of vesicles seated 
upon red bases, and arranged along the course of nerves 
upon which there are ganglia. (Fig. 75.) The vesicles 
are at first filled with serum that afterward may become 
cloudy. They do not tend to break down of themselves, 
but are frequently ruptured by accident. The size of the 
groups varies greatly. There may be but a few vesi- 
cles or a large number of them closely crowded together. 
Sometimes a group is no larger than a three-cent piece, 
and sometimes it is several inches in its longest diameter. 
Sometimes the vesicles may run together and form blebs. 
The shape of the groups is always irregular. There may 
be but two or three groups or a score of them. In nearly 
all cases the disease is unilateral, though it is not uncom- 
mon for one or two groups to be found close to the mid- 
dle line, on the side opposite to the site of the disease, and 
cases of double zoster occur, though very rarely. All the 
groups do not come out at once, but, as it were, by a se- 
ries of outbreaks, the earliest ones to appear usually being 
those nearest the point of exit of the nerve. The erup- 
tion is usually at its height in a week, the vesicles drying 
up, forming a crust and falling off, leaving a red mark 
that soon fades. The whole duration of the disease is 
from ten days to three or four weeks. 



61G 



DISEASES OF THE SKW. 



In many, if not most cases, the patient experiences 
neuralgic pain in the nerve along whose course ^the erup- 
tion is about to appear. This is sometimes wanting, and 
generally lessens or disappears when the eruption appears. 
Sometimes the pain is severe during the duration of the 
eruption, and after it is gone. Tender points may often 
be found over the points of exit of the nerves, just as are 
found in neuralgia, In some patients there will be fever 

Fig. 75. 




Zoster of arm. 

before the outbreak of the vesicles or the successive ap- 
pearance of new groups. The vesicular stage is preceded 
by an erythemato-papular stage. Very rarely some of 
the groups may abort at this stage. Exceptionally, zoster 
may occur on both sides of the body. In nearly all 
cases the disease does not recur. Exceptionally, a patient 
may have several attacks of the disease. 

Most cases of zoster occur upon the trunk, and, it is 
said, especially on its right side. It also occurs upon the 
face, on branches of the fifth nerve, when it may involve 
the eye, and produce blindness by destructive ulceration. 
The neck may be affected, and with it the arm. The leg, 
too, may suffer. Generally the eruption does not reach 
further down than the elbow and knee, though it may oc- 
cupy the forearm and hand, leg and foot. In rare in- 
stances the tongue and pharynx may be affected. Various 



ZOSTER. 617 

names are used to designate the location of the eruption, 
such as zoster frontalis, ophthalmicus, cervicalis, intercos- 
talis, genito-cruralis, and the like. 

In rare cases hemorrhage may occur into the vesicles, 
or they may be purulent from the start, or they may ul- 
cerate, or become gangrenous. The neuralgia may con- 
tinue in old or debilitated subjects in so severe a manner 
as to threaten the exhaustion of the patient from pain and 
loss of sleep. Or pruritus, hyperesthesia, or anaesthesia 
may be left for some time after the disappearance of the 
eruption. Or paralysis of motion may follow the attack, 
as well as atrophy of muscles. Scars will follow the dis- 
ease if ulceration has occurred. 

Etiology. Zoster occurs more often in children than 
in adults. Sex seems to have little influence. It follows 
upon injuries to nerves in some cases, and has been asso- 
ciated with caries of the ribs. It has been known to oc- 
cur while the patient was taking arsenic. It occurs fre- 
quently in the damp cold weather of the spring and 
autumn, so much so as to give rise to epidemics. Indeed, 
some regard the disease as infectious on account of the 
epidemic character it sometimes has. Some cases seem to 
arise from peripheral irritation of cutaneous nerves. A 
descending peripheral neuritis of the spinal ganglion is 
regarded by Crocker as the condition most frequently as- 
sociated with the disease. In a great number of cases 
disease of the ganglia upon the posterior roots of the spinal 
nerves has been found post mortem. When the fifth 
nerve is affected it is the Gasserian ganglion that is dis- 
eased. Zoster may arise from injury, as a wound of a 
nerve-trunk, and then we may have an ascending zoster, 
the first group being nearest the point of injury. 

Diagnosis. Zoster in most cases is readily recognizable. 
It differs from eczema in having larger vesicles that do not 
tend to rupture ; in its patchy character, the patches being 
located along certain nerve-trunks ; in the neuralgia that 
accompanies it ; and in the definite course that it runs. 
Herpes facialis or progenitalis sometimes resembles zoster 



618 DISEASES OF THE SKIN. 

quite closely, but in them there will often be a history of 
previous attacks ; they will not occur so markedly as 
groups of vesicles upon one side alone ; and they will not 
be preceded by the same amount of neuralgia. By some 
authorities herpes and zoster are considered to be the 
same disease. 

Treatment. The most important part of the treat- 
ment of zoster is to prevent the breaking of the vesicles, 
and the possible ulceration that would follow and leave 
scars. To this end we should avoid ointments and use 
dusting powders, such as oxide of zinc, bismuth, starch, 
guiacol, five per cent, with starch powder, or, what is 
better, we should paint the vesicles with flexible collodion 
Avith or without morphine, which sometimes seems to abort 
the formation of vesicles. It is also advisable to cover 
the eruption with a soft linen bandage to prevent rubbing. 
If the vesicles have become broken and ulceration has en- 
sued, then we have to treat the ulcers on surgical principles. 

To relieve the pain of zoster the galvanic current gives 
the best results, one sponge electrode being placed over 
the spine, and a steel roller electrode attached to the other 
pole and passed around the groups for ten or fifteen minutes 
once or twice a day. A current-strength of two or three 
milliamperes may be used, and, if it can be done, the last 
application should be made just before going to bed. Other 
means are hypodermatics of morphine ; blistering over the 
root of the nerve ; guiacol as mentioned above, and the 
use of the menthol cone or oil of peppermint. Phosphide 
of zinc, one-third of a grain every three hours, is thought 
by some to relieve the pain and limit the eruption. For 
the persistent neuralgia that at times follows these cases, 
arsenic, or strychnine, iron, quinine, cod-liver oil, and a 
good nutritious diet are necessary. Opium may have to 
be given to allay pain and procure sleep. 

Prognosis. Most cases of zoster run a favorable course 
and get well of themselves. It is only in old or debilitated 
people that w r e need fear any serious results. There is 
always the possibility of the occurrence of ulceration and 



ZOSTER. 619 

gangrene, though it is not to be expected in the vast ma- 
jority of cases. The popular opinion that if zoster occurs 
on both sides at once and forms a girdle the patient will 
die, has no foundation in fact as such an occurrence is un- 
known. 



APPENDIX. 



The following formula? are given as guides in the preparation of 
prescriptions for the treatment of skin diseases. Many, if not all of 
them, have been well tried and their value proved : 





A. BATHS. 




Water Baths : 






Cold . 

Cool . 
Tepid 
Warm 
Hot . 




40° - 65° F. 
65° - 75° F. 
85° - 95° F. 
95°-100° F. 
100°-110° F 



Wet Pack. Wrap patient in wet sheet and roll up in a blanket. 
After twenty to thirty minutes remove the pack, rub dry, and anoint 
with oil or ointment. Useful to remove the scales in psoriasis and to 
diminish hyperemia. 



Medicated Baths. 
of water, add for 



To an ordinary bath-tubful, say thirty gallons 





Bran bath . 


2 to 6 lbs 


bran. 




Potato-starch bath 


lib. 


starch. 




Gelatin bath 


1 to 3 lbs 


gelatin. 




Linseed ' ' 


lib. 


linseed. 




Marshmallow bath 


4 lbs. 


marshmallow. 




Size bath . 


. 2 to 4 " 


size. 


These baths are useful in erytL 


ematous, itchy, and scaly diseases. 








To bath. 




Bicarbonate of soda b 


ith . 


2 to 10 ounces. 




Carbonate of potassiui 


2i bath 


2 to 6 " 




Borax bath 




3 " 


These 


baths are useful in ecz 


ema, psoriasis, urticaria, prurigo, and 


pruritic 


diseases. 




To bath. 




Nitric acid bath 




1 ounce. 




Muriatic acid bath 
Or mav use of each 




. 1 " 



Of use in chronic pruritic diseases. 



622 



APPENDIX. 



Iodine Bath : 



Iodine .... 
Iodide of potassium, vel . 
Liquor potassse, 
Glycerin ..... 

Useful in scrofulous and squamous diseases. 



To bath. 
I to 1 drachm. 

% ounce. 
1 to 2 ounces. 

2 " 



Bromine Bath : 

Bromine 

Iodide of potassium 

Same indications as iodine bath. 



To bath. 
. 20 drops. 
2 ounces. 



To bath. 
2 to 4 ounces. 



Sulphuret of potassium 
Used in scabies, chronic eczema, lichen, and psoriasis. 



Startin's Compound Sulphur, Bath : 

Precipitated sulphur 

Hyposulphite of soda 

Water ..... 



To bath. 
2 ounces. 
1 ounce. 
1 pint. 



Same indications as the sulphuret of potassium bath. 



Mercurial Bath : 







To bath. 


Bichloride of mercury 
Hydrochloric acid . 
Water . 




3 drachms 
1 drachm. 
1 pint. 


Jsed in pityriasis rubra and the syphilides. 




B. INTEKNAL USE. 




. Turpentine Emulsion : 






R. 01. terebinthinse, 
01. limonis, 
Mucilag. acacise, 
Aquse, 


rt\,x-xxx ; 

"lii ; 

gss; 
5ss; 


0.66-2 

16 
16 


1 



M. 

Sig. A teaspoonful three times a day immediately after meals. One 
quart of barley water to be drunk during twenty -four hours. ( Crocker. ) 
Used in psoriasis, eczema and hyperemias, 



APPENDIX. 



623 



2 Mixed Treatment : 

a. R. Hydrarg. bichlor., 
Potass, iodid., 
Tinct. cinchon. co., 
Aqure, 

Sig. One draclim in water t. i. d. one hour after meals. (Taylor. ) 

03-. 13 



gr- J-ii.l ; 
5iv-vnj 

giijss 

gss; 



16-32 

112 

16 



06-. 2 



M. 



b. R. Hydrarg. biniod., gr. ss-ij 

Ammon. iodid., 5 ss > 

Potass, iodid., 5y-SJ J 

Syr. aurant. cort., ^J ss 5 

Tinct. aurant. cort., 5J ' 



2 

8-32 

48 

4 

100 



Aqute, ad giij ; 

Sig. One-half ounce t. i. d. after meals. ( Keyes. ) 



M. 



c. R. Hydrarg. bichlor. vel \ •_•• 

Hydrarg. biniod., J & • J J 

Potass, iodid., 5j~ij I 

Inf. gent, co^ vel \ *. 

Syr. sarsaparilla? co., J o > 

Sig. One drachm t. i. d. after meals. 
These three are used in syphilis. 



4-8 
128 



06-. 13 



M. 



3. R. 01. gurjun.. 
Liquor calcis, 


Si; 

Siy ; 


33133 
100 M 


Sig. One-half ounce twice a day. 






Used in leprosy. 







4. R. Tinct. cannabis indicpe, rrix-xxx ; 0.66-2| 
Pulv. tragacanth. co., gr. x; ( 

Aqua-, §j ; 32| 

Used in pruritus and prurigo. (Bulkley. ) 



M. 



5. Startin' s Mixture 



R. 


Magnesii sulphat., 


5 v J- xi J ; 


20-30 




Ferri sulphat., 


5j ; 


3 




Ac. sulphur, dil., 


3y; 


6 




Syr. pruni virgin., 


S.i; 


24 




Aquse, 


ad giv ; 


100 



M. 

Sig. One drachm t. i. d. after meals, through a tube. As a laxa- 
tive and tonic. 



624 



APPENDIX. 



6. Asiatic Pil:ls 



R. 



Ac. arsenici, 
Pulv. pip. nigrse, 
Gummi acacise, 
Aquae, 



gr. lxvj. 

3ix. 



aa q. s. 



M. 



Div. in pil. no. dccc. 

Sig. One to three pills a day after meals and increase to tolerance. 
Used in psoriasis. 

7. R. Pil. hydrarg., 9ij ; 2 

Ferri sulpliat. exsic, Qj ; 1 

Ext. opii, gr. v ; 33 M. 

Div. in. pil. no. xl. 
Sig. One t. i. d. (Taylor. ) 
Used in syphilis. Sulphate of quinine may be substituted for the 



Hydrarg. chlor. mitis, 


gr. jss ; 




1 


Ferri lactatis, 


g r - iij ; 




2 


Sacch. alb., 


gr. xv ; 


3 





R 



Ft. in pulv. no. x. 
Sig. One to four daily. 
Used in infantile syphilis. 



(Monti.) 



M. 



C. EXTERNAL USE. 

a. Caustics. 



1. Cosine's Paste: 



R . Ac. arseniosi, gr. x ; 

Hydrarg. sulphuret. rub., 3 ss > 

Ungt. rosse vel \ * 

Sacch. alb., / 5 ss ' 

To destroy epithelioma or other new growths. 



66 



M. 



2. 3farsden' s Paste : 

R. Pulv. ac. arseniosi, \ 
Pulv. gummi acacise, j 



5.i 



M. 



Mixed with water to form a paste just before using, and apply to not 
more than one square inch at a time. 

Same indications as last. 



. Bougard' s Paste : 


APP. 


END1 


X. 






R . Wheat flour, 
Starch, 


} 




aa 


60 parts. 




Arsenic, 








1 part. 




Cinnabar, 
Sal ammoniac 


} 




aa 


5 parts. 




Corrosive sublimate, 
Sol. chlor. of zinc @ 


52°, 




w part. 
245 parts. 


M 



625 



Grind first six ingredients to a fine powder, then mix them in a mortar. 
Add solution of acid, slowly stirring. Keep in earthen jar. May add 
cocaine up to 20 per cent, to allay pain. 

Sig. Apply accurately to part ; keep on for thirty hours ; follow 
with poultice. 



4. Depilatory Paste : 

R. Barii sulphid., ^ij ; 8| 

Zinci oxidi, "I , 10 

Amyli, } aa 5^i 12 | M. 

Make into a paste with water and apply a thin coating for ten to fif- 
teen minutes, then clean off and apply a bland ointment. 

5. Salicylic Acid (Crocker): 

R. Glycerini, § j ; 32 

Ac. salicyl. , q. s. ; M. 

Make in consistency of thick cream. To lessen painfulness of appli- 
cation may add 

R . Ac. carbolici vel \ ^ . J 

Creosoti, J ^ J ' , M. 

Used to destroy warts, lupus, and epidermic thickenings. 

6. Vienna Paste : 

R. Calcis, \ - M 

Potass^, f a p. a?. M. 

Make into a paste with alcohol just before using. 
Used in lupus and scrofulides. 

7. Canquoiri s Paste : 

R. Zinci chlor., \ _- ,_. . 

r< | aa oJ > 



Ammon. chlor. 

Pulv. amyli, 5jss ; 

Aqua?, q. s. ; 

Make into a paste at time of using. 
Used to destroy lupus, epithelioma, and the like. 
40 



M. 



626 



APPENDIX. 



8. Middlesex Hospital Paste 

R . Zinci chlor. , 
Liq. opii sed. , 
Amyli, 
Aquae, 

Same indications as last. 



9. R 

Mix before using 



Zinci nitrat. , 
Micse panis, 



aa 3iv ; 

5Jss; 

SJ ; 



1 part. 

2 parts. 



b. Lotions. 



1. Belladonna Lotion 



R. Tr. belladon., \ 

Glycerini, J 
Aquse, 

Sig. For erysipelas. (Pifiard. ) 



aa 1 part. 
8 parts. 



2. Bismuth Lotion: 

R. Bismuth, subnitrat. 
Zinci oxidi, 
Glycerini, 
Hydrarg. biehlor., 
Aquas rosse, 

For rosacea and hyperaemic conditions. 

3. Calamine Liniment: 

9ij 



R. Pulv. calamin., 
Zinci oxidi, 
Linimenti calcis, 



SJ 



For erythema, eczema, and hyperaemic conditions. 

4. Calamine Lotion : 

R . Pulv. calamin. , 



Zinci oxidi, 
Glycerini, 
Aq. calcis, 
Aq. rosae, 

For erythema and eczema. 
5. Carbolic Acid Lotion : 

R 



9j; 

o ss ; 

ad giv ; 
( Buckley. ) 



6 

32. 



M. 



M. 



M. 



gr. vijss ; 




3 ss ; 


2 


TTlxv; 


1 


gr- I 1 




S; 


32 



016 



M. 



61) 



M. 



Ac. carbol., 

Alcoholis 

Aquas, 

Sig. For erysipelas. ( White. ) 



Si; 

aa Oss 



20 

36 

200 



4 
250 



M. 



M. 



APPENDIX. 



627 



6. Car r on Oil : 

R. Aq. calcis, 
01. oliva? vel 
01. lini, 

For burns. 



Equal part* 



M. 



7. Coster' s Paint : 

R . Iodini, 

01. picis liquidae, 

8. Forts C. C. C. Mixture: 

R. Chrysarobin. , \ 
01. cadini, J 
Ac. carbolici, 
Ac. oleici, 
Sig. In psoriasis. 



oj-u ; 
gj; 



4-81 
30 



aa 2 parts. 

1 part. 
50 parts. 



M. 



R . Sapo. oliva? prep. 
01. rusci, \ 
Glycerini, / 


> 


aa gj ; 




100 
25 


01. rosmarini, 
Alcoholis, 




5J SS 
ad gvn 


; 


4 
200 


10. Kaposi's Tar Lotion: 










R . 01. rusci, 

Etheris sulpliuris ; 
Alcoholis, 
Filtra et adde 

01. lavandulse, 


} 




50 
aa 75 

2 


parts. 
(< 

it 


Used in psoriasis. 










11. KummerfekV s Lotion : 










R . Spts. camphora?, 
Spts. lavandulee, 
Sulph. pra?cip., 
Aq. cologniensis, 
Aq. destil., 


} 


aa 


5 ss ; 

gr. xv 

5J; 
gij; 


2 

1 

4 

60 


For cosmetique. 










12. Liquor Picis Alkalinus : 










R . Picis liquidae, 
Potass, causticse, 
Aquae, 






Si]; 
gj; 

5 y ; 


64i 

32 

20|' 



M. 



M. 



M. 



M. 



( Dissolve the potassa in the water and add slowly the tar in a mortar 
with friction. ) 

In chronic eczema, or, diluted ten to twenty times, in acute eczema. 



628 



APPENDIX. 



13. Lotto Alba : 

R . Potassse sulphurat. , 
Zinci sulphat. , 
Aquse rosse, 

In acne and rosacea. 



aa 3j ; 



4 

128 



M. 



14. Lotio Ac. Boracis : 

R . Ac. borac:s, ^h vel q. s. ; 16 

Etheris sulph. methyl., gv ; 160 



Spts. vini rect. 



ad gxx; 640 



M. 



In ringworm, after washing with hot water and soap and drying. 
(A. Smith.) 



15. Lotio Plumbi et Opii : 

R . Liq. plumbi subacetat. dil. 
Tinct. opii, 
Aquse, 

In acute inflammatory conditions. 



} aa Sj ; 32 
ad Oj ; 500 



M. 



16. R. Naphtholi, gr. xv ; 1 

Spts. sapo. viridis, 5 V J 5 25 

Alcoholis, gjss ; 50 

Bals. peruv., gtt. xxx ; 2 

Sulph. loti, 3iJ ss ; 10 

In sycosis. ( Kaposi. ) 



M. 



17. R . Amyli glycerolis, \ 
01. cadini, J 

Sapo. viridis, 

Sig. In psoriasis. External use. 



100 parts. 
5 ". 



M. 



18. Piffard' s Substitute for Tar: 

R. Ac. salicyl., gr. x-xxx ; 0.66-2 

01. lavandulse, 5ij ss j 10 

01. citronellse, 3 SS I 2 

01. pini sylvestris, gij I 64 

01. ricini, gjss ; 48 

In eczema capitis. 



M. 



19. R . Sodii hypophosphitis, Sj ; 30| 

Glycerini, g ss I l^i 

Aquse, gviij ; 250 1 

For dermatitis venenata. ( Morrow. ) 



M. 



APPENDIX. 



629 



20. Sulphur Lotion : 
R . Sulphuris loti, 
Alcoholis, 
Etheris, 
Glycerini, 
Potass, carb., 
Aq. rosae, 

Used in acne. 



21. Thymol Lotion : 

R. Thymol., "I 

Liq. potassae, J 
Glycerini, 
Aq. sambuci, 
For sebofrhoea sicca capitis, 
the amount of thymol. 

22. Tinctura Saponis Viridis: 
R . Sapo. viridis, ") 



aa 3ij 



250, M. 



aa oJ ; 4 

§ ss ; 151 

gviij ; 250; M. 
Also for pruritus cutaneus, with double 



Alcoholis, 



23. Tinct, Saponis Co. of Hebra 
R . 01. cadini, 

Sapo. viridis, 

Alcoholis, 
Filtra et adde 

Spts. lavandulae, 
Stimulant in chronic eczema. 



Equal parts, 
aa 5J ; 

3y; 



M. 



HI 



M. 



24. Vleminckafs Solution : 

R . Calcis vivae, ^iv ; 161 

Sulphur, sublimat., gj ; 321 

Aq. destillat., gx ; 320| M. 

Boil together with constant stirring until the mixture measures six 
fluid ounces, then filter. 
Useful in scabies, psoriasis, and acne. 



M. 



25. R . Zinci oxidi, 


5 iv ; 


16 ; 


Ac. carbol., 


3J ; 


4 


Aquae calcis, 


Oj; 


500j 


For dermatitis venenata. 


(White.) 
c. Ointments. 




1. Bassorin Paste : 






R . Bassorin, 




48 parts. 


Dextrin, 




25 " 


Glycerin, 




10 " 


Water, 


ad 


100 " 



M. 



630 



APPENDIX. 



2. Gelatine Paste (Unna) : 
R . Zinci oxidi, 
Gelatini, 
Glycerini. 
Aquse, 



M. 



Heat in water bath before using. As a protective dressing and ex- 
cipient. 



3. Bismuth Ointment: 

R . Bismuth! subnit. , \ 

Kaolini, / aa 

Vaselini, 
For chloasma. ( Unna. ) 

4. R. Ac. borici, 

Ac. salicylici, 
Ungt. aqua? rosae, 
For chromidrosis. (Van Harlingen. ) 

5. Chrysarobin Ointment : 

R. Chrysarobin., 
Ac. salicylici, 
Plasment. vel \ 
Adipis, J 

Used in psoriasis and ringworm. 



SJss ; 




7 


5vj ad 


Si ss ; 


30 


gr. x ; 
gr. xv 


7 


1 
30 


gr. 1; 




3 


gr. x ; 






Sj; 




30 



M. 



M. 



M. 



6. R. Chrysarobin., 
Ichthy ol. , 
Ac. salicyl., 
Ungt. simpl., 

Used in leprosy. (Unna 



(Hebra.) 



gr. lxxv ; 
gr. xxx ; 



7. Diachylon Ointment : 
R. 01. olivse, 

Plumbi oxidi, 
Boil together to a good consistence and add 

Ol. lavandulse, 5y I 






8. R. Hydrarg. ammon., \ -. 

Bismuthi subnit. , J a ' 
Ungt. aq. rosa?, 
Used in lentigo. (Hardaway. ) 

9. R. Hydrarg. ammon., 

Hydrarg. chlor. mitis, 
Vaselini, 



5j; 



9j-ij ; 
Si; 



100 



480! 
120 



SI 



5-10 

10-20 

100 



M. 



M. 



M. 



Used in seborrhoea sicca capitis and pityriasis capitis. ( Bronson. 



APPENDIX. 




10. R. Hydrarg. bichlor., 
Ac. carbol., 
Ungt. zinci oxidi, 


gr. J-v ; 
gr. xx ; 

5J; 


1-5 
20 

500 


Used in lichen ruber. (Unna. ) 






11. R . Ac. salicylici, gr. x ; 
Ungt. hydrarg. ox. rub., 3J '■> 
Ungt. aquae rosse, 3 V J j 


41 
24 


For blepharitis. ( Webster. ) 






12. R. Hydrarg. protiodid. , 
Hydrarg. ammon., 
Ungt. simplicis, 


gr. v-xv ; 
gr. x-xxx ; 


0.33-1 

0.66-2 
32 



631 



Used in acne. (Duhring. ) 

13. R . Ungt. lanse, 

Ac. acetici, 
Adepis benzoat. , 
Sulph. precip., 

Used in acne. (Unna. ) 

14. R. Hydrarg. sulph. rubri, gr. xv 

Sulph. sublimat, 5 V J 5 

Adipis, ad giij ; 

01. bergamot., q. s. 

Used in sycosis. (Behrend. ) 

15. R. Ungt. diachyli (Hebra), \ -- 

Ungt. zinci oxidi, J 

Ungt. hydrarg. ammon., 
Bismuthi subnitrat. , 

In sycosis. (Bobinson. ) 



5J SS 

5Jss 



M. 



M. 



M. 



M. 



M. 



M. 



16. Lassar 1 s Paste : 

R . Zinci oxidi, 
Amyli, 
Vaselini, 



aa 3i 

3iv 



32 



M. 



As a protective application and as excipient for other drugs. 
17. R . Zinci oxidi, 40 



Zinei oxidi, 
Cretse preparat. 
Liquor plumbi, 
01. lini, 



aa 20 



Mix the two first together, and the two last together, and add one 
part to the other. Use as a protective in excema. (Unna.) 



632 APPENDIX. 



18. Naphthol Ointment: 






R . /3-naphthol. , 

Cretse preparat., 
Sapo. viridis, 
Adipis, 
Used in scabies. ( Kaposi. ) 


gijss ; 
SJss ; 
ad giij ; 


15 

10 

50 

100 


19. Naphthol Ointment : 






R. /3-naphthol. , 
Sulph. precip., 
Vaselini, \ 
Sapo. viridis, J 


10 

50 

aa 25 


parts. 

a 

u 


Used in acne. ( Lassar. ) 






20. R. Ac. salicylici, 

Sulphur, precip., 

Lanolini, 

Vaselini, 


2-3 
10-15 

70 
18 


parts. 

u 

a 


For chromophytosis. ( Brocq. ) 






21. R. Sulphur., 

Potass, carb., 
Adip. benzoat., 
01. chamomilis, 


Sj; 
5ij; 

3ss; 


32 

8 

160 

2 


Used in scabies. (Wilson. ) 






22. HelmericK s Ointment: 






R . Sulphur. , 

Potass, carb., 
Adipis, 


SJ; 
S V11 J ; 


30 

15 

250 


Used in scabies. 






23. Wilkinson's Ointment (Hebra) 






R . Sulphuris, \ 
01. cadini, J 
Sapo. viridis, \ 
Adipis, / 
Cretse preparat. , 


aa, 5 SS 1 
aa BJ I 


16 

32 
10 


Used in scabies. 






24. R. 01. fagi, \ 
Flor. sulph., J 
Pulv. cretse alb., 
Adipis, \ 
Sapo. viridis, j 


aa Sijss ; 

5J; 

aa 3v ; 


10 
4 

20 



M. 



M. 



M. 



M. 



M. 



M. 



M. 



In sycosis. (H. Hebra. 



APPENDIX. 



633 



25. R. 01. cadini, \ 

Zinci oxidi, j 
Ungt. aquae rosa?, 
In chronic eczema. 

26. R . Zinci oxidi, "J 

Zinci carbonat., J 
Ungt. aq. rosse, 

In sycosis after shaving. ( T. 



aa 3ss-j 

5J; 



ad 



3j 



2-4 
30! 

4 | 
32| 



M. 



M. 



Fox. 



Anti-pruritic Powder 
R . Camphori, 
Zinci oxidi, 
Amyli, 



Miscellaneous. 



5s* 



M. 



(Bulkley.) 



2. Corn Remedy: 

R . Ac. salicylici, 

Ext. cannabis indica?, 
Alcoholis, 
iEtheris, 
Collodion flex., 

Apply with brush three times a day for one week, 
out corn. (Vigier. ) 



gr. xv ; 


1 




gr. viij ; 
fflxv; 


1 


5 


TT\xl; 


2 


66 


ttlhtxv ; 


5 





M. 

Soak feet and pick 



Ejpilating Stick : 
R . Cerse fiavse, 

Laccse in tabulis, 
Picis burgundicae, 
Gummi damar., 



5"j ; 12 

5iv ; 16 

3x; 40 

gjss ; 48 M. 

Make in stick one-half to one inch in diameter and two inches long. 
(Bulkley.) 



4. Glycerin Jelly : 

R . Gelatini, 
Glycerini, 
Aqua?, 

5. Glycerole of Subacetate of Lead , 

R . Plumbi acetat. , 
Plumbi oxidi, 
Glycerini, 



gr. xxv ; 


1 


gr. ccxxv ; 


15 


5iv; 


16 



60 



gr. cxx ; 
gr. lxxxiv 

5 J ; 



6 
32! 



M. 



M. 



Digest the lead in the glycerin heated to 300° F. in an oil bath for 
half an hour, constantly stirring. Filter in a chamber heated to 300° F. 

Dilute from three to seven times with water and glycerin, and use as 
astringent and sedative in chronic eczema. ( Squire. ) 



INDEX. 



ABSCESS, 62 
Acantholysis bullosa, 231 
Acanthosis nigricans, 63 
Acarus scabiei, 492 
Achorion Schoenleinii, 270 
Achroma, 346 
Acid, oleic, 48 

oxynaphthoic, 51 
Acne, 64 

adenoid, 368 

albida, 381 

artificialis, 79 

arthritique, 80 

atrophica, 80 

atrophique, 80 

bromic, 167 

cachecticorum, 80 

cornee, 469 

diagnosis of, 70 

erythematosa, 478 

etiology of, 66 

fiuente, 509 

follicularis, 139 

frontalis, 80 

indurata, 66 

iodic, 169 

keloid, 171 

lupoid, 80, 361, 368 

mentagra, 518 

miliare scrofuleuse, 80 

necrotica, 80 

papulosa, 64 

pathology of, 70 

pilaris, 80 

prognosis of, 79 

punctata, 64, 139 

punctuee, 139 

pustulosa, 64 

rodens, 80 

rosacea, 478 

rosee, 478 

scrofulosorum, 80 
i, 508 



Acne, cornea, 469 

sebacee, 509 

cornee, 328, 469 

simplex, 64 

sycosis, 518 

syphilitica, 539 

tar, 79 

treatment of, 72 

ulcereuse, 80 

varioliformis, 80, 383 

vulgaris, 64 
Acrochordon, 82, 279 
Acrodermitite, 82 
Acrodynia, 82 
Acromegaly, 82 
Actinomycosis, 82 
Addison's keloid, 387 
Adeno-carcinoma, 83 
Adenoma, 83 
Adenotrichie, 518 
Adeps lanse, 48 
Agnine, 48 
Ainhum, 84 
Airol, 48 
Albinism, 346 

Aleppo boil, bouton, or evil, 84 
Algidite progressive, 499 
Alopecia, 85 

adnata, 85 

areata, 94 

etiology, 96 
pathology, 98 
diagnosis, 98 
treatment, 99 
prognosis, 101 

circumscripta, 94 

follicularis, 94 

furfuracea, 90 

pityrodes, 90 

prematura idiopathica, 86 
symptomatica, 90 

senilis, 86 

syphilitica, 92 



636 



INDEX. 



Alopecie cicatricielle innominee, 

281 
Alphos, 453 
Alumnol, 49 
Anaesthesia, 101 
Anatomical tubercle, 591 
Angiokeratoma, 102 
Angioma, 103, 396 

cavernosum, 397 

pigmentosum et atrophieum, 
110 
Angioma serpiginosum, 103 
Angiomyoma, 393 
Angioses, 104 
Anhidrosis, 104 
Anonychia, 104 
Anthrarobin, 49 
Anthrax, 122, 474 
Area celsi, 94 

Area occidentalis diffluens, 94 
Argyria, 105 
Aristol, 49 

Arrectores pilorum, 27 
Asiatic pills, 624 
Asteatosis, 105 
Atheroma, 507 
Atrophia cutis, 110 

pilorum propria, 105 

unguium, 109 
Atrophoderma, 110 

albidum, 113 

idiopathica diffusa, 113 

pigmentosum, 110 

senilis, 11.4 

striatum et maculatum, 114. 
Aussatz, 337 

BAD disorder, 527 
Baelzer's disease, 115 
Baker's itch, 212 
Baldness, 85 

circumscribed, 94 
Barbadoes leg, 226 

glandular disease of, 226 
Barbers' itch, 518, 578 
Bartfinne, 518 

parasitische, 578 
Bartflechte, 518 
Bassorin, 47 
Baths, 621 
Birth mark, 396 
Blackheads, 139 



Blasenausschlag, 419 
Blutfleckenkrankheit, 469 
Blutschwar, 285 
Boil, 285 

Bougard' s paste, 625 
Bouton, 64 
Brandrose, 116 
Brandschwar, 122 
Bricklayers' itch, 212 
Bromic acne, 167 
Bromidrosis, 116 
Bucnemia, tropica, 226 
Bulla, the, 32 
Bulpiss, 118 
Bunion, 118 
Burning, 43 
Burns, 147 

CACOTBOPHIA folliculorum,. 
332, 469 
Calculi, cutaneous, 382 
Callositas, 119, 331 
Callus, 119 
Calotte, the, 273 
Calvezza, 85 
Calvities, 85 

Cancer, chimney sweep' s, 235 
Cancer en cuirasse, 126 

epithelial, 232 

skin, 232 

tubereux, 325 
Cancroi'de, 232 
Canites, 119 
Canquoin' s paste, 625 
Caraate, 431 
Carbuncle, 122 
Carcinoma, 125 

lenticulare, 125 

melanodes, 126 

tuberosum, 126 
Carron oil, 627 
Causalgia, 127 
Chalastodermia, 178 
Chalazion, 381 
Chaleur du foie, 127 
Chancre, 528 
Chap, 127 
Charbon, 474 
Cheilitis glandularis, 127 
Cheiro-pompholyx, 439 
Chelis or cheloide, 325 
Chicken-pox, 605 



INDEX. 



637 



Chilblain, 149 
Chloasma, 127, 132 

uterinum, 128 
Chorioblastosis, 130 
Chorionitis, 500 
Chromidrosis, 130 
Chromophytosis, 132 
Cicatrix, the, 34 
Claret stain, 396 
Classification, 53 
Clastothrix, 106 
Clavus, 137 

syphiliticus, 138 
Clou, 285 
Cnidosis, 598 
Cochin-China leg, 226 
Cold sore, 293 
Collodion, 46 

Colloid degeneration of the skin, 
138 

milium, 138 
Comedo, 139 
Condyloma lata, 537 

acuminata, 607 
Congelatio, 149 

Connective tissue, subcutaneous, 21 
Cor, 137 
Corium, 20 
Corn, 137 
Cornu cutaneum, 143 

humanum, 143 

Cosme' s paste, 624 
Corpuscles of Meissner, 22 
Corpuscles of Krause, 23 
Coster's paint, 627 
Couperose, 478 
Creolin, 49 
Crust, the, 33 
Crusta lactea, 206 
Cute, 431 
Cutis anserina, 144 

pendula, 178 

tensa chronica, 500 
Cyanopathie cutanee, 130 
Cyanosis, 144 
Cyst, dermoid, 507 

sebaceous, 507 
Cysticercus cellulose cutis, 144 
Cysto-adenoma, 145 



D 



A.CTYLITIS, 556 
Dandruff, 438, 510 



Dartre pustuleuse mentagre, 518 

erythemo'ide, 247 

rongeante, 369 

yive, 182 
Dartrous diathesis, 145 
Dasyma, 305 

Denuvium capillorum, 93 
Demodex folliculorum, 141 
Dermalgie, 145 
Dermatalgia, 145 
Dermatitis, 146 

ambustionis, 147 

blastomycetic, 147 

bullosa/ 231 

calorica, 147 
Dermatitis congelationis, 149 

contusiforme, 258 

epidemica, 150 

erythematosa, 247 

exfoliativa, 151 
etiology, 153 
pathology, 154 
diagnosis, 154 
treatment, 154 
neonatorum, 155 

fungoid, 390 

gangrenosa, 156 
infantum, 158 

glandularis erythematosa, 362 

herpetiformis, 159 
etiology, 162 
diagnosis, 163 
pathology, 164 
treatment, 164 

malignant papillary, 405 

medicamentosa, 165 

papillaris capillitii, 171 

papillomatosa capillitii, 171 

repens, 172 

seborrheica, 221 

traumatica, 173 

venenata, 174 

x-ray, 173 
Dermatol, 49 
Dermatolysis, 178 
Dermatomycosis favosa, 265 
Dermatomykosis tonsurans, 575 
Dermato-sclerosis, 500 
Dermatosis Kaposi, 110 
Desmoids, 279 
Diabetic eruptions, 179 
Diachvlon ointment, 630 



638 



INDEX. 



Diagnosis, 28 
Diaskop, 45 
Distichiasis, 179 
Don'ts, 58 
Dracontiasis, 291 
Durillon, 119 
Dysidrosis, 439 

ECDEKMOPTOSIS, 383 
Ecphyma globulus, 180 
Ecthyma, 180 

infantile gangreneux, 158 
terebrant de l'enfance, 158 
Eczema, 182 

etiology, 187 
pathology, 189 
diagnosis, 189 
treatment, 193 
prognosis, 204 
ani, 204 
aurium, 205 
barbae, 206 
capitis, 206 
crurum, 209 
exfoliativum, 151 
foliaceum, 151 
genitalium, 209 
hypertrophicum, 390 
infantile, 218 
intertrigo, 210 
labiorum, 211 
mammarum, 211 
mammillarum, 211 
manuum, 212 
marginatum, 573 
narium, 215 
palpebrarum, 215 
pedum, 216 
seborrhoicum, 221, 509 
etiology, 223 
pathology, 224 
diagnosis, 224 
treatment, 225 
tuberosum, 390 
unguium, 216 
universale, 217 
Eiterpusteln, 180 
Ekzem, 182 
Elastic webbing, 47 
Elephantiasis, 226 

etiology, 228 
pathology, 229 



Elephantiasis, diagnosis, 229 
treatment, 230 
prognosis, 231 
arabum, 226 
Indica, 226 
Grsecorum, 337 
Emol, 49 
Emphysema, 231 
Endurcissement athrepsique, 499 1 
Eph elides, 336 
Ephidrosis, 302 
cruenta, 292 
tincta, 130 
Epidermis, 17 
Epidermolysis, 231 
Epilating stick, 633 
Epithelialkrebs, 232 
Epithelioma, 232 

etiology, 235 
pathology, 236 
diagnosis, 236 
treatment, 237 
prognosis, 239 
adenoides cysticum, 240 
contagiosum, 383 
multiple benign cystic, 240 
Epitheliomatose, eczematoide de la, 
mamelle, 405 
pigmentaire, 110 
Equinia, 240 
Erbgrind, 265 

Eruption, recurrent summer, 301 
Eruptions, color of, 42 
configuration of, 36 
feigned, 276 
location of, 34 
ringed, 36 
Erysipelas, 241 

suffusum, 247 
Erysipeloid, 246 
Erythanthema, 247 
Erythema, 247 

caloricum, 248 
elevatum diutinum, 26L 
exudativum, 254 
etiology, 258 
pathology, 259 
diagnosis, 260 
treatment, 260 
prognosis, 261 
fugax, 250 
gangrenosum, 262 



INDEX. 



639 



Erythema, hypersemicum, 247 

induratum, 262 

intertrigo, 248 

iris, 256 

heve, 250 

multiforme, 254 

neonatorum, 252 

nodosum, 258 

paratrimma, 250 

pernio, 149, 248 

roseola, 251 

scarlatiniforme, 252 

simplex, 248 

traumaticum, 248 

urticans, 251 
Erytheme centrifuge, 362 

indure des scrofuleux, 262 

noueux, 258 

papuleux desquamatif, 432 
Erythrasma, 263 
Erythrodermie exfoliante, 151 
Ervthromelalgia, 264 
Esthiomene, 264, 369 
Europhene, 50 
Exanthemata, 265 
Excoriation, the, 33 

FAKCY, 240 
Favus, 265 

etiology, 269 
pathology, 270 
diagnosis, 272 
treatment, 273 
Feu sacre", 241 
Feuergiirtel, 615 
Feuermal, 396 
Fever blister, 293 
Fibroma, 277 

fungoides, 390 
lipomatoses, 609 
molluscum, 277 
pendulum, 279 
Fibromyoma, 393 
Fikosis, 518 
Filaria sanguinis hommis, 229 

medinensis, 291 
Filmogen, 50 
Finnen, 64 

Fischschuppenausschlag, 313 
Fish-skin disease, 313 
Fissure, 33 
Flea bites, 280 



Flechte, fressende, 369 

kleien, 132 

nassende, 182 

scheerende, 572, 575 
Fleckenmal, 394 
Fleshworms, 139 
Fluxus sebaceus, 508 
Folliculitis, 280 

barbae, 518 

decalvans, 281 

pilorum, 518 
Foot, tubercular disease of, 284 
Fragilitas crinium, 105 
Framboesia, 171, 614 
Freckles, 336 
Frieselausschlag, 379 
Frost bite, 149 
Fuchsine, 50 

Fungous foot of India, 284 
Furunculi atonici, 180 
Furunculus, 285 

GALE, 490 
Gallacetophenone, 50 
Gangrene, symmetrical, 157 
Gangrenes multiples cachectiques, 

158 
Gefassmal, 396 
Gelanthum, 50 
Gelatin preparations, 46 
Geromorphisme cutane, 290 
Glanders, 240 
Glossy skin, 114 
Glycerin Jelly, 633 
Glycerole of subacetate of lead, 633 
Gneis, 509 

Gommes scrofuleuses, 505 
Goose-flesh, 144 
Granuloma, 291 

fungoides, 390 
Grayness, 119 
Grubs, 139 
Grutum, 381 

Guinea-worm disease, 291 
Gumma, 546 

scrofulous, 505 
Giirtelkrankheit, 615 
Gutta rosacea, seu rosea, 478. 

HAAKMENSCHEN, 306 
Ha?matidrosis, 292 
Hsemidrosis, 292 



640 



INDEX. 



Hsemorrhoea petechialis, 469 
Hair, anatomy of, 23 

blanching of, 119 

discolorations of, 292 

ringed, 121 

superfluous, 305 
Hand and foot disease, 427 
Harlequin foetus, 315 
Hauthorn, 143 
Hautrose, 241 
Hautrothe, 247 
Hautsclereme, 500 
Hautschmerz, 145 
Hautwurmer, 139 
Heat eruption, 182 
Helmerich's ointment, 632 
Hemiatrophia facialis progressiva, 

114 
Hernia carnosa, 226 
Herpes circine parasitaire, 575 

circinatus, 159, 572, 575 
bullosus, 298 

esthiomenos, 369 

facialis, 293 

febrilis, 293 

gestationis, 159, 298 

iris, 256 

labialis, 293 

phlyctsenoides, 159 

preputials, 296 

progenitalis, 296 

pustulosus mentagra, 518 

squamosus, 575 

tonsurans, 575 
barbae, 578 
maculosus, 432 

tonsurante, 575 

zoster, 615 
Herpetide, 299 

exfoliative, 151 
Hide-bound disease, 500 
Hidrocystoma, 299 
Hirsuties, 305 
History of case, 43 
Hitzblatterchen, 182 
Hives, 598 _ 
Homines pilosi, 306 
Horn, cutaneous, 143 
Hiihnerauge, 137 
Hutchinson's teeth, 556 
Hyalom der Haut, 138 
Hydradenomes eruptifs, 240 



Hydradenitis, 286 
Hydroa, 159, 301 

bulleux, 159 

febrilis, 293 

herpetiforme, 160 

puerorum, 301 

vacciniforme, 301 

vesiculeux, 257 
Hydroxylamine. 50 
Hyperesthesia, 302 
Hyperidrosis, 302 

oleosa, 513 
Hyperkeratosis follicularis, 332 

excentrica, 442 
Hypertrichosis, 305 

etiology, 308 

treatment, 310 
TCHTHALBIN, 50 
1 Ichthyol, 51 
Ichthyose anserine des scrofuleux, 

332 
Ichthyosis, 313 

Ichthyosis follicularis, 328, 332, 
469 

linguae, 349 

palmaris et plantaris, 331 

sebacea, 509 

sebacea cornea, 469 
Idrosis, 302 
Ignis sacer, 615 
Impetigo, 317 

contagiosa, 318 
etiology, 320 
diagnosis, 321 
treatment, 323 
prognosis, 323 

herpetiformis, 159, 323 

parasitica, 318 

simplex, 318 
Induratio telee cellulosae, 499 
Inflammatory fungoid neoplasm, 

390 
Initial lesion of syphilis, 528 
Intertrigo, 248 
Iodic acne, 169 
Ionthus, 64 
Itch, 490 

barber's, 518, 578 

bricklayers', 212 

grocers', 212 

prairie, 443 

washerwoman's, 212 



INDEX. 



641 



TUCKBLATTEKN, 444 

KAHLHEIT,85 
Kreisfleckige, 94 
Kelis, 325 
Keloid, 325 

of Addison, 387 

of Alibert, 325 
Keratolysis exfoliativa, 328 
Keratoma follicularis, 315 

palmare et plantare heredi- 
tarium, 331 
Keratosis epidermica, 315 

diffusa, 315 

follicularis, 328, 469 

intrauterina, 315 

palmaris et plantaris, 331 

pilaris, 332 
Kerion, 333, 576 

Celsi, 333 
Kleienflechte, 132 
Knollenkrebs, 325 
Koltun, 439 
Kratze, 490 
Kraurosis vulva 3 , 335 
Krause's corpuscles, 23 
Kupferfinne, 478 
Kupferrose, 478 
Kupfrigesgesicht, 478 
Kummerfeld' s lotion, 627 
Kwena, 335 

T ANOLIN, 48 

1j Lassar' s paste, 631 
Leberfiecken, 127 
Leichdorn, 137 
Lentigo, 336 

maligna, 110 
Leontiasis, 337 
Lepothrix, 337 
Lepra, 337, 453 
alphos, 453 
arabum, 337 
Leorosy, 337 

etiology, 343 
patbology, 343 
diagnosis, 344 
treatment, 344 
Lombardian, 418 
Leucasmus, 346 
Leucoderma, 346 

41 



Leucopathia, 346 

unguium, 349 
Leucoplakia, 349 
Lichen circinatus, 509, 510 

hypertrophicus, 354 

menti, 518 

obtusus, 354 

pilaris, 332 

planus, 350 

ruber acuminatus, 356 
moniliformis, 354 

scrofulosorum, 359 

scrofulosus, 359 

simplex, 185 

spinulosum, 469 

tropicus, 380 

verrucosus, 354 
Lineee albicantes, 115 
Linsenflecke, 336 
Linsenmal, 394 
Liodermia essentialis cum melan- 

osi, etc., 110 
Lipoma, 361 
Liquor anthracis, 51 

gutta percha?, 45 

picis alkalinus, 627 
Liver spot, 127 
Lotio alba, 628 

plumbi et opii, 628 
Lousiness, 411 
Lues, 527 

Lupoid acne, 80, 361, 368 
Lupus erythematodes, 362 

erythematosus, 362 
etiology, 364 
pathology, 365 
diagnosis, 365 
treatment, 366 
prognosis, 367 

exedenes, 369 

exfoliativus, 369 

exulcerans, 369 

hypertrophicus, 369 

lymphaticus, 377 

miliaris, 368 

papillaire verruqueux, 591 

pernio, 368 

sclereux, 591 

sebaceus, 362 

superficialis, 362 

tuberculosa, 369 

verrucosus, 369, 591 



642 



INDEX. 



Lupus, vorax, 369 
vulgaris, 369 

etiology, 371 

pathology, 372 

diagnosis, 372 

treatment, 373 

prognosis, 376 
Lustseuche, 527 
Lymphadenie cutanee, 390 
Lymphangiectasis, 376 
Lymphangiectodes, 377 
Lymphangioma, 377 

tuberosum multiplex, 378 
Lymphangio-myoma, 393 
Lymphatics, 22 
Lymphodermia perniciosa, 390 
Lymphorrhagica pachydermia, 377 

MACCHIE epatiche, 127 
Macule, the, 28 
Maculae cserulese, 414 

et striae atrophica, 115 
Madura foot, 284 
Mai de los pintos, 431 

de la rosa, 418 
Mai roxo, 418 
Malingering, 276 
Malleus, 240 
Malum venereum, 527 
Mamillaris maligna, 405 
Marsden' s paste, 624 
Mask, 127 
Masque, 127 
Measles, 386 

German, 486 
Meissner's corpuscles, 22 
Melanoderma, 128 
Melasma, 128 
Melanosarcoma, 486 
Melanosis lenticularis progressiva, 

110 
Melastearrh^e, 130 
Melitagra, 206 
Mentagra, 518 
Microsporon anomseon, 433 

furfur, 134 

minutissimum, 263 
Middlesex Hospital paste, 626 
Miliaria, 379 
Miliary fever, 381 
Milium, 381 
Milk crust, 206 



Mitesser, 139 

Mole, pigmentary, 394 

Molluscum, cholesterique, 609 

contagiosum, 383 

epitheliale, 383 

fibrosum, 277 

pendulum, 277 

sebaceum, 383 

sessile, 383 

simplex, 277 

verrucosum, 383 
Morbilli, 386 
Morbus elephas, 226 

gallicus, 527 

hispanicus, 527 

indicus, 527 

italicus, 527 

maculosus Werlhoffii, 471 

neapolitanus, 527 

pedicularis, 411 
Morphcea, 387 
Morpion, 413 
Morvan's disease, 390 
Morve, 240 
Moth patch, 127 
Mother's mark, 394 
Mucous patch, 536 
Muslin, plaster, 46 

salve, 46 
Myasis externa dermatosa, 390 
Mycetoma, 284 
Mycosis framboesiodes, 171 
Mycosis fungoides, 390 

microsporina, 132 
Myoma, 392 
Myronin, 48, 51 
Myxoedema, 393 

YTiEVUS araneus, 570 
1\ flammeus, 397 

lipomatodes, 394 

pigmentosus, 394 

pilosus, 394 

sanguineus, 396 

simplex, 397 

spilus, 394 

tuberosus, 397 

unius lateris, 396 

vascularis, 396 

venous, 396 

verrucosus, 394, 396 
Nails, anatomy of, 25 



INDEX. 



643 



Nails, atrophy of, 109 

ingrowing, 410 
Naftalan, 51 
Naphtol, 51 
Narbenkeloid, 326 
Neoplasm, inflammatory fungoid, 

390 
Nerven nsevus, 396 
Nerves, 22 
Nesselausschlag, 598 
Nesselsuch, 598 
Nettle rash, 598 
Neuralgia of the skin, 145 
Neuroma cutis, 400 
Nodosites non-erythemateuses des 

arthritiques, 400 
Nodules, ephemeral cutaneous, 400 
subcutaneous rheumatismal, 
401 
N odulus laqueatus, 401 
Noli me tangere, 232, 369 
Nosophen, 51 

H7DEMA cutis, 401 
Vfh neonatorum, 402 
CEsypus, 48 
Oleum choenoceti, 4 

physeteris, 48 
Onychatrophia, 109 
Onychauxis, 403 
Onychia, 404 
Onychitis, 404 
Onychogryphosis, 403 
Onychomycosis, 405, 580 
Ophiasis, 94 
Osmidrosis, 116 
Osteosis cutis, 405 

PACHYDERMATOCELE, 178 
Pachydermia, 226 
Pacinian corpuscles, 23 
Paget' s disease of the nipple, 405 
Pain, 44 

Panaris nerveux, 408 
Panaritium, 410 
Panne hepatique, 127 
Panniculus adiposus, 21 
Papillar Geschwulste der Haut, 
beerschwamahnliche multiple, 
390 
Papilloma, 408 

area elevatum, 409 



Papilloma, neuropathic, 396 

neuroticum, 396 
Papule, the, 30 
Parangi, 614 
Parakeratosis scutalaris, 409 

variegata, 409 
Parasitic diseases, 409 
Paronychia, 410 
Pastes, 46 

Patients, examination of, 44 
Pedicularia, 411 
ediculosis, 411 

etiology, 414 
diagnosis, 416 
treatment, 417 

capitis, 412 

pubis, 413 

vestimentorum, 412 
Pelade, 94 

Peliosis rheumatica, 472 
Pellagra, 418 
Pemfigo, 419 
Pemphigus, 419 

etiology, 423 
pathology, 424 
diagnosis, 424 
treatment, 425 
prognosis, 426 

circinatus, 159 

contagiosus, 422 

foliaceus, 422 

gangrsenosus, 158 

neonatorum, 422 

pruriginosus, 159, 422 

vegetans, 421 

vulgaris, 420 
Pencils, paste, 46 

salve, 46 
Perifolliculitis suppurees et con- 
glomerees en placards, 427 
Perisarcoma, 475 
Perleche, 429 
Pernio, 149 
Phagmesis, 429 
Phlegmasia malabarica, 226 
Phlyzacia agria, 180 
Phthiriasis, 411 
Phyto-alopecia, 94 
Pian, 614 

ruboi'de, 171 
Piebald-skin, 346 
Piedra^ 429 



644 



INDEX. 



Pigment, 20 
Pigmentflecken, 127 
Pigmentmal, 394 
Pimple, 64 
Pinta, 431 
Pityriasis, 509 

alba atrophicans, 431 

capitis, 438 

circine et margine, 432 

maculata et circinata, 432 

nigricans, 130 

parasitaire, 132 

pilaris, 332 

rosea, 432 

rubra, 151 

rubra pilaris, 434 

simplex, 438 

tabescentium, 438 

versicolor, 132 
Plasment, 47 
Plica Polonica, 438 
Plique polonaise, 439 
Podelcoma, 284 
Poils accidentels, 305 
Poliosis, 119 
Poliotes, 119 
Poliothrix, 119 
Polyidrosis, 302 
Polytrichia, 305 
Pompholyx, 299, 419, 439 
Porcellanfriesel, 598 
Porrigo, 206, 265 

contagiosa, 318 

decalvans, 94 

favosa, 265 

furfurans, 575 

lavalis, 265 

lupinosa, 265 

scutulata, 265 
Porrigophyta, 265 
Porokeratosis, 442 
Portwine mark, 396 
Pox, 527 
Prairie itch, 443 
Prickly heat, 379 
Pronunciation, scheme of, 62 
Prurigo, 444 
Pruritus cutaneus, 43, 447 

hiemalis, 449 

aestivalis, 449 

senilis, 449 
Pseudo-erysipelas, 453 



Pseudo-leucsemia cutis, 453 

lupus, 147 
Psora, 453 
Psoriasis, 453 

etiology, 458 
pathology, 460 
diagnosis, 460 
treatment, 462 
prognosis, 468 
buccalis, 349 
Psorospermose folliculaire vege- 

tante, 328 
Psorospermosis follicularis cutis, 

469 _ 
Pterygium, 469 
Purpura, 469 
Pustula maligna, 474 
Pustule, the, 31 

QUINQUAUD'S disease, 283 
Quirica, 431 

RAYNAUD'S disease, 157 
Ked gum, 380, 475 
Kesorbin, 48 
Eesorcin, 51 
Eete Malpighii, 19 
Rheumatism of skin, 145 
Eheumatokelis, 475 
Ehinophyma, 475, 480 
Ehinoscleroma, 475 
Ehus-poisoning, 174 
Einged eruptions, 36 
Eingskurv, 575 
Eingworm, 572 

crusted, 265 

honeycomb, 265 

of the beard, 578 

of the body, 572 

of the nails, 580 

of the scalp, 575 

Polish, 439 
Eisopola, 241 
Eisipola lombarda, 418 
Eitter's disease, 155 
Eodent ulcer, 235 
Eogna grossa, 180 
Eosacea, 478 
Eose, la, 241 
Eosee, 478 
Eose rash, 247 
Eoseola, 251 



INDEX, 



645 



Roseola, syphilitica, 532 

pityriaca, 432 
Eotheln, 486 
Eothlauf, 241 
Eotz, 240 
Eubeola, 386, 486 
Eun-around, 410 
Eupia, 545 

escharotica, 158 

QT. ANTHONY'S fire, 241 

O Salol, 52 

Salt rheum, 182 

Salzfluss, 182 

Sarcocele, Egyptian, 226 

Sarcoma, 486 

cutis multiple, 390 
Sarcomatosis generalis, 390 
Satyriasis, 337 
Sauriasis, 313 
Sauroderma, 469 
Scabies, 490 
Scald head, 206, 265 
Scale, the, 33 
ScaU or scald, 182, 206 
Scalp, hygiene of, 88 
Scar, hypertrophied, 327 

keloidal, 326 
Scarlatina, 498 
Schmeerfluss, 509 
Schuppenflechte, 453 
Scissura pilorum, 105 
Sclerem der Neugeboren, 499 
Sclerema adultorum, 500 

neonatorum, 499 
Sclereme des adults, 500 
Scleriasis, 500 
Sclerodactylie, 502 
Scleroderma, 500 

circumscribed, 387 

neonatorum, 499 
Sclerodermic, 500 
Scleroma adultorum, 500 
Sclerostenosis, 500 
Scrofulide boutonneuse benigne, 
444 

erythemateuse, 362 

taberculeuse, 369 
Scrofuloderma, 504 

ulcerative, 390 

verrucosum, 591 
Scurvy, land, 471 



Sebaceous glands, anatomy of, 26 
Seborrhagia, 508 
Seborrhoea, 508 

etiology, 512 
diagnosis, 513 
treatment, 514 

congestiva, 362 

nigricans, 130 
Seborrheal eczema, 221 
Shingles, 615 
Sicosi parasitaria, 578 
Siderosis, 517 

Skin, anatomy and _ physiology of, 
17 

blood vessels of, 21 

lesions of, 28 

muscles of, 27 

neuralgia of, 145 
Skin splints, 47 

cancer, 232 
Smallpox, 605 
Soaps, medicated, 47 
Sommersprosse, 336 
Spargosis, 226 
Spedalskhed, 337 
Sphaceloderma, 156 
Spider cancer, 570 
Spilosis poliosis, 119 
Spotted sickness, 431 
Startin's mixture, 623 
Stearrhcea, 508 

nigricans, 130 
Steatoma, 507 
Steatorrhea, 508 
Steresol, 52 
Stigmata bleeding, 292 
Stonepock, 64 
Stratum corneum, 19 

mucosum, 19 
Stria? et macula? atrophica?, 114 
Strophulus, 380 

albidus, 381 

prurigineux, 444 
Sudamina, 379 
Sudatoria, 302 
Sudor urinosus, 598 
Sweat glands, anatomy of, 26 

blue, 131 

green, 131 

red, 131 

yellow, 131 
Sweating, excessive, 302 



646 



INDEX. 



Sycosis, 518 

etiology, 520 
pathology, 521 
diagnosis, 521 
treatment, 523 
prognosis, 527 
barbae, 518 
capillitii, 171 
framboesia, 171 
menti, 518 
non parasitica, 518 
parasitaire, 578 
parasitica, 578 
Syphilis, 527 
General 

diagnosis, 550 
etiology, 551 
treatment, 556 
prognosis, 567 
hereditary, 551 
Syringo-cystadenoma, 240 
Syringomyelia, 568 

TACHE de feu, 396 
hepatique, 127 

ombrees, 414 

vasculaire, 396 
Tactile corpuscles, 22^ 
Tanne, 139 
Tar, 52 

acne, 99 
Tattoo, 568 
Teigne du pauvre, 265 

faveuse, 265 

pelade, 94 

tondante, 575 

tonsurante, 575 
Telangiectasis, 569 
Tetter, 182 
Therapeutic notes, 45 
Thilanin, 52 
Thiol, 52 
Thiosavonale, 52 
Tinctura saponis viridis, 629 
Tinea amiantacea, 509 

asbestina, 509 

barbae, 578 

circinata, 572 

decalvans, 94 

favosa, 265 

ficosa, 265 

imbricata, 574 



Tinea, kerion, 333 

lupinosa, 265 

maligna, 265 

nodosa, 429, 571 

sycosis, 578 

tondens, 575 

tonsurans, 575 

vera, 265 

versicolor, 132 
Tinna, 431 
Traumatacin, 45 
Trichauxis, 305 
Trichiasis, 571 
Trichoclasia, 106 
Trichoma, 439 
Trichomycosis nodosa, 429 
Trichomykosis capillitii, 333 

favosa, 265 
Trichonosis cana, 119 

discolor, 119 

poliosis, 119 
Trichophytosis, 572 

diagnosis, 574, 577, 578, 

580 
etiology, 580 
pathology, 581 
treatment, 583 
prognosis, 590 

barbae, 578 

capitis, 575 

corporis, 572 

unguium, 581 
Trichophytie circinee, 572 

sycosique, 578 
Trichophyton tonsurans, 581 
Trichoptylose, 106 
Trichorrhexis nodosa, 106 
Trichosis hirsuties, 305 

plica, 439 

poliosis, 119 
Tropical big leg, 226 
Tubercle, the, 30 

anatomical, 591 
Tuberculum sebaceum, 381 
Tuberculosis cutis, 591 

verrucosa cutis, 591 
Tumenol, 52 
Tumor, the, 32 

multiple fungoid papilloma- 
tous, 390 
Tyloma, 119 
Tylosis, 119 



INDEX. 



647 



Tylosis, linguae, 349 

palmae et planta?, 331 

ULCEK, 34, 594 
grave, 284 

perforating, of the foot, 426 

rodent, 235 

scrofulous, 505 

syphilitic, 548 

tropical phagedenic, 597 
Ulerythema, 362, 597 

acneiforme, 598 

ophryogenes. 597 
. sycosiforme, 283, 597 
Uridrosis, 598 
Urticaire, 598 
Urticaria, 598 

oedematosa, 401 

pigmentosa, 603 

VACCINAL eruptions, 604 
Varicella, 605 

gangrenosa, 158 
Variola, 605 
Varus, 64 
Venereal wart, 557 
Verole, 527 
Verruca, 606 

necrogenica, 591 
Verrue, 606 

telangiectasique, 102 
Verruga endemic, 615 
Vesicle, the, 31 
Vienna paste, 625 



Vitiligo, 346 

capitis, 94 
Vitiligoidea, 609 
Vleminck's solution, 629 

WAET, 606 
Warts, post-mortem, 591 
Warze, 606 

Washerwoman's itch, 212 
Washleather skin, 609 
Weichselzopf, 439 
Wen, 507 
Wheal, the, 32 
Whelk, 64 
Whitlow, 404, 410 
melanotic, 487 
Wildfire, 241 
Wundrose, 241 
Wilkinson's ointment, 632 

XANTHELASMA, 609 
Xanthelsamoidea, 604 
Xanthoma, 609 

diabeticorum, 613 
Xeroderma, 313 

pigmentosum, 110 
Xerodermic pilaire, 332 



Y 



7AWS, 614 



7OXA, 615 
L Zoster, 615 



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CLIMATOLOGY. Solly, p. 26 ; Hayem & Hare, 14. [Hamilton, 12. 

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MENTAL DISEASES. Clouston, p. 6 ; Savage, 24 ; Folsom, 10. 

BACTERIOLOGY. Abbott, p. 2 ; Vaughan & Novy. 30; Senn's 
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BUMSTEAD (P. J.) AND TAYLOR (R. W.). THE PATHOLOGY 
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BURCHARD (HENRY H.). DENTAL PATHOLOGY AND THER- 
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CASPARI (CHARLES JR.). 

For Students and Pharmacists. 
680 pages, with 288 illustrations. 

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The author's duties as Professor 
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CHEYNE (W. WATSON). THE TREATMENT OF WOUNDS, 



A TREATISE ON PHARMACY. 
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ULCERS AND ABSCESSES. 
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need at any moment. The sections 
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CLARKE (W. B.) AND LOCKWOOD (C. B.). THE DISSECTOR'S 

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CLELAND (JOHN). A DIRECTORY FOR THE DISSECTION OF 

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CLINICAL MANUALS. See Series of Clinical Manuals, page 25. 

CLOUSTON (THOMAS S.). CLINICAL LECTURES ON MENTAL 

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CLOWES (FRANK). AN ELEMENTARY TREATISE ON PRACTI- 
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COAKLEY (CORNELIUS G.). THE DIAGNOSIS AND TREAT- 
MENT OF DISEASES OF THE NOSE, THROAT, NASO- 
PHARYNX AND TRACHEA. In one 12mo. volume of about 400 
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COATS (JOSEPH). A TREATISE ON PATHOLOGY. In one vol. 
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COLEMAN (ALFRED). A MANUAL OF DENTAL SURGERY 

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handsome octavo vol. of 412 pages, with 331 engravings. Cloth, $3.25. 

CONDD3 (D. FRANCIS). A PRACTICAL TREATISE ON THE DIS- 
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CORNDL. (V.). SYPHILIS: ITS MORBID ANATOMY, DIAGNO- 
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8vo. volume of 461 pages, with 84 illustrations. Cloth, $3.75. 

CULBRETH (DAVID M. R.). MATERIA MEDICA AND PHAR- 
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CULVER (E. M.) AND HAYDEN (J.R.). MANUAL OF VENE- 
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CUSHNY (ARTHUR R.). TEXT-BOOK OF PHARMACOLOGY. 

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DAI/TON (JOHN C). A TEEATISE ON HUMAN PHYSIOLOGY. 

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DOCTEINES OF THE CIRCULATION OF THE BLOOD. In 

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DAVENPORT (F. H.). DISEASES OF WOMEN. A Manual of 

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DAVIS (EDWARD P.). A TREATISE ON OBSTETRICS. FOR 
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A work unequalled in excellence. 
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Decidedly one of the best text- 



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From a practical standpoint the 
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DAVIS (F. H.). LECTURES ON CLINICAL MEDICINE. Second 
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DE LA BECHE'S GEOLOGICAL OBSERVER. In one large octavo 
volume of 700 pages, with 300 engravings. Cloth, $4. 

DENNIS (FREDERIC S.) AND BILLINGS (JOHN S.). A SYS- 
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Complete work in four very handsome octavo volumes, containing 
3652 pages, with 1585 engravings and 45 full-page plates in colors and 
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London Lancet. 

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No work in English can be con- 
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DERCUM (FRANCIS X., EDITOR). A TEXT-BOOK ON 
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of any of its class. — Jour, of Amer- of this country. — Alienist and Neu- 



ican Med. Association. 

The most thoroughly up-to-date 
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— American Journal of Jnsanity. 



rologist. 

The best text-book in any lan- 
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DE SCHWEINITZ (GEORGE E.). THE TOXIC AMBLYOPIAS. 

Their Classification, History, Symptoms, Pathology and Treatment. 
Very handsome octavo, 240 pages, 46 engravings, and 9 full-page 
plates in colors. Limited edition, de luxe binding, $4. Net. 



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DRAPER (JOHN C.). MEDICAL PHYSICS. A Text-book for Stu- 
dents and Practitioners of Medicine. In one handsome octavo volume 
of 734 pages, with 376 engravings. Cloth, $4. 

DRUITT (ROBERT). THE PRINCIPLES AND PRACTICE OF 
MODERN SURGERY. A new American, from the twelfth London 
edition, edited by Stanley Boyd, F.R. C.S. In one large octavo 
volume of 965 pages, with 373 engravings. Cloth, $4 ; leather, $5. 

DUANE (ALEXANDER). THE STUDENT'S DICTIONARY OF 
MEDICINE AND THE ALLIED SCIENCES. New edition. Com- 
prising the Pronunciation, Derivation and Full Explanation of Medi- 
cal Terms, with much Collateral Descriptive Matter. Numerous Tables, 
etc. Square octavo of 658 pages. Cloth, $3.00; half leather, $3.25; 
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The standard dictionary for medi- 
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The best student's dictionary.— 
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Medical students are here provided 
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ing tbeir professional education. — 
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Far superior to any dictionary for 
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DUDLEY (E. C). THE PRINCIPLES AND PRACTICE OF 
GYNECOLOGY. Handsome octavo of 652 pages, with 422 illustra- 
tions in black and colors. Cloth, $5.00, net ; leather, $6.00, net. Just 
ready. 

DUNCAN (J. MATTHEWS). CLINICAL LECTURES ON THE 
DISEASES OF WOMEN. Delivered in St. Bartholomew's Hospital. 
In one octavo volume of 175 pages. Cloth, $1.50. 

DUNGLISON (ROBLEY). A DICTIONARY OF MEDICAL SCI- 
ENCE. Containing a full explanation of the various subjects and 
terms of Anatomy, Physiology, Medical Chemistry, Pharmacy, Phar- 
macology, Therapeutics, Medicine, Hygiene, Dietetics, Pathology, Sur- 
gery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecol- 
ogy, Obstetrics, Pediatrics, Medical .Jurisprudence, Dentistry, etc., etc. 
By Robley Dttnglison, M. D., LL. D., late Professor of Institutes 
of Medicine in the Jefferson Medical College of Philadelphia. Edited 
by Richard J. Dtjnglison, A. M., M. D. Twenty-first edition, thor- 
oughly revised and greatly enlarged and improved, with the Pronuncia- 
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In one magnificent imperial octavo volume of 1225 pages. Cloth, $7 ; 
leather, $8 Thumb-letter Index for quick use, 75 cents extra. 
The most satisfactory and authori- Pronunciation is indicated by the 
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terms. — The Charlotte Med. Journal, book is wholly satisfactory. — Uni- 

Covering the entire field of medi- versity Medical Magazine. 
cine, surgery and the collateral The volume is entitled to be called 
sciences, its range of usefulness can an encyclopaedia rather than a die- 
scarcely be measured. — Med. Record, tionary. — Brooklyn Med. Journal. 

DUNHAM (EDWARD K.). MORBID AND NORMAL HIS- 
TOLOGY. Octavo, 450 pages,with 363 illustrations. Cloth, $3.25, net. 
Just ready. 

EDES (ROBERT T.). TEXT-BOOK OF THERAPEUTICS AND 
MATERIA MEDICA. In one 8vo. volume of 544 pages. Cloth, $3.50 ; 
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EDIS (ARTHUR W.). DISEASES OF WOMEN. A Manual for 
Students and Practitioners. In one handsome 8vo. volume of 576 pages, 
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EGBERT (SENECA). A MANUAL OF HYGIENE AND SANI- 
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ELLIS (GEORGE VTNER). DEMONSTRATIONS IN ANATOMY. 
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EMMET (THOMAS ADDIS). THE PRINCIPLES AND PRAC- 
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Third edition, enlarged and revised. In one large 8vo. volume of 880 
pages, with 150 original engravings. Cloth, $5 ; leather, $6. 

ERICHSEN (JOHN E.). THE SCIENCE AND ART OF SUR- 
GERY. A new American from the eighth enlarged and revised Lon- 
don edition. In two large octavo volumes containing 2316 pages, with 
984 engravings. Cloth, $9 ; leather, $11. 

ESSIG (CHARLES J.). PROSTHETIC DENTISTRY. See American 
Text-Books of Dentistry, page 2. 

FARQUHARSON (ROBERT). A GUIDE TO THERAPEUTICS. 

Fourth American from fourth English edition, revised by Frank 
Woodbury, M. D. In one 12mo. volume of 581 pages. Cloth, $2.50. 

FTELD (GEORGE P.). A MANUAL OF DISEASES OF THE 
EAR. Fourth edition. In one octavo volume of 391 pages, with 73 
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To those who desire a concise j It is just such a work as is needed 

work on diseases of the ear, clear by every general practitioner. — 

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mends itself in the highest degree. ' 

FLINT (AUSTIN). A TREATISE ON THE PRINCIPLES AND 

PRACTICE OF MEDICINE. Seventh edition, thoroughly revised 

by Frederick P. Henry, M. D. In one large 8vo. volume of 1143 

pages, with engravings. Cloth, $5.00 ; leather, $6.00. 

The work has well earned its lead- [ The leading text-book on general 

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element of treatment is by no means [ the United States. — Northwestern 

neglected ; in fact, by the editor a : Lancet. 

fresh stimulus is given to this neces- The best of American text-books 

sary department by a comprehensive on Practice. — Amer. Medico-Surgical 

study of all the new and leading the- Bulletin. 

rapeutic agents. — Medical Record. ! 

A MANUAL OF AUSCULTATION AND PERCUSSION ; of 

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MEDICAL ESSAYS. In one 12mo. vol. of 210 pages. Cloth, $1.38. 

ON PHTHISIS : ITS MORBID ANATOMY, ETIOLOGY, ETC. 

A Series of Clinical Lectures. In one 8vo. volume of 442 pages. 
Cloth, $3.50. 



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FOLSOM (O. F.). AN ABSTRACT OF STATUTES OF U. S. 

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Cloth, $1.50. With Clouston on Mental Diseases (new edition, see 
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FORMULARY, POCKET, see page 32. 

FOSTER (MICHAEL). A TEXT-BOOK OF PHYSIOLOGY. New 

(6th) and revised American from the sixth English edition. In one 
large octavo volume of 923 pages, with 257 illustrations. Cloth, $4.50 ; 
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This single volume contains all 
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Monthly. 

For physician, student, or teacher 
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FOTHERGD1L (J. MLLNER). THE PRACTITIONER'S HAND- 
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To have a description of the 
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FOWNES (GEORGE). A MANUAL OF ELEMENTARY CHEM- 
ISTRY (INORGANIC AND ORGANIC). Twelfth edition. Em- 
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12mo. volume of 1061 pages, with 168 engravings, and 1 colored 
plate. Cloth, $2.75 ; leather, $3.25. 

FRANKLAND (E.) AND JAPP (F.R.). INORGANIC CHEMISTRY. 

In one handsome octavo volume of 677 pages, with 51 engravings and 
2 plates. Cloth, $3.75 ; leather, $4.75. 

FULLER (EUGENE). DISORDERS OF THE SEXUAL OR- 
GANS IN THE MALE. In one very handsome octavo volume of 
238 pages, with 25 engravings and 8 full-page plates. Cloth, $2. 



It is an interesting work, and one 
which, in view of the large and 
profitable amount of work done in 
this field of late years, is timely and 
well needed. — Medical Fortnightly. 

The book is valuable and instruc- 



tive and brings views of sound 
pathology and rational treatment to 
many cases of sexual disturbance 
whose treatment has been too often 
fruitless for good. — Annals of 
Surgery. 



FULLER (HENRY). ON DISEASES OF THE LUNGS AND AIR 
PASSAGES. Their Pathology, Physical Diagnosis, Symptoms and 
Treatment. From second English edition. In one 8vo. volume of 475 
Cloth, $3.50. 



GANT (FREDERICK JAMES). THE STUDENT'S SURGERY. _ A 
Multum in Parvo. In one square octavo volume of 845 pages, with 
159 engravings. Cloth, $3.75. 

GD3BES (HENEAGE). PRACTICAL PATHOLOGY AND MOR- 
BID HISTOLOGY. In one very handsome octavo volume of 314 
pages, with 60 illustrations, mostly photographic. Cloth, $2.75. 

GD3NEY (V. P.). ORTHOPEDIC SURGERY. For the use of Practi- 
tioners and Students. In one 8vo. vol. profusely illus. Preparing. 



Lea Beothebs & Co., Philadelphia and New Yoek. 11 

GERRISH (FREDERIC H.). A TEXT-BOOK OF ANATOMY. 
By American Authors. Edited by Frederic H. Gerrish, M. D. In 
one imp. octavo volume, richly illustrated. Preparing. 

GOULd) (A. PEARCE). SURGICAL DIAGNOSIS. In one 12mo. 
vol. of 589 pages. Cloth, $2. See Student's Series of Manuals, p. 27. 



GRAY (HENRY). ANATOMY, DESCRIPTIVE AND SURGICAL. 

New and thoroughly revised American edition, much enlarged in text, 
and in engravings in black and colors. In one imperial octavo volume 
of 1239 pages, with 772 large and elaborate engravings on wood. Price 
of edition with illustrations in colors : cloth, $7 ; leather, $8. Price 
of edition with illustrations in black : cloth, $6 ; leather, $7. 



This is the best 
upon Anatomv 



single volume 
in the English 
language. A thorough knowledge 
of the subject is acquired without 
consulting other books. As a work 
of reference for the surgeon or prac- 
titioner it has no superior. — Uni- 
versity Medical Magazine. 

This edition has been revised to 
adapt it thoroughly to the require- 
ments of teachers and students of 
the present day. The illustrations 
in Gray's Anatomy have always 
been one of its especial features ; 
each bone, ligament, muscle, nerve, 
artery, and tissue has been appro- 
priately labelled, and in late editions 
have appeared in colors where 
essential. Gray's Anatomy affords 
the student more satisfaction than 
any other treatise with which we 
are familiar. — Buffalo Med. Journal. 

The most largely used anatomical 
text-book published in the English 
language. — Annals of Surgery. 



Gray's Anatomy, in spite of the 
efforts which have been made from 
time to time to displace it, still holds 
first place in the esteem of both 
teachers and students. — The Brook- 
lyn Medical Journal. 

Particular stress is laid upon the 
practical side of anatomical teach- 
ing, and especially the Surgical 
Anatomy. — Chicago Med. Recorder. 

The foremost of all medical text- 
books. — Medical Fortnightly. 

Gray's Anatomy should be the 
first work which a medical student 
should purchase, nor should he be 
without a copy throughout his pro- 
fessional career. — Pittsburg Medical 
Review. 

This new edition of Gray is a 
matchless treatise upon Human Ana- 
tomy. Medical students and prac- 
titioners desiring a complete library 
on anatomy will make no mistake 
in purchasing Gray. — Tri-StateMed. 
Journal. 



GRAY (LANDON CARTER). A TREATISE ON NERVOUS AND 
MENTAL DISEASES. For Students and Practitioners of Medicine. 
New (2d) edition. In one handsome octavo volume of 728 pages, with 
172 engravings and 3 colored plates. Cloth, $4.75 ; leather, $5.75. 



We have here what has so often 
been desired — an up-to-date text- 
book upon nervous and mental dis- 
eases combined. A well-written, 
terse, explicit, and authoritative vol- 
ume treating of both subjects is a 
step in the direction of popular de- 
mand. — The Chicago Clinical Re- 
view. 

"The word treatment," says the 
author, " has been construed in the 
broadest sense to include not only 
medicinal and non-medicinal agents, 



but also those hygienic and dietetic 
measures which are often the physi- 
cian's best reliance." — The Journal 
of the American Medical Association. 
The descriptions of the various 
diseases are accurate and the symp- 
toms and differential diagnosis are 
set before the student in such a way 
as to be readily comprehended. The 
author's long experience renders his 
views on therapeutics of great value. 
— The Journal of Nervous and Men- 
tal Disease. 



12 Lea Brothers & Co., Philadelphia and New York. 



GREEN (T. HENRY). AN INTRODUCTION TO PATHOLOGY 
AND MORBID ANATOMY. New (8th) American from the eighth 
London edition. In one handsome octavo volume of 582 pages, with 
216 engravings and a colored plate. Cloth, $2.50, net. Just ready. 



A work that is the text-book of 
probably four-fifths of all the stu- 
dents of pathology in the United 
States and Great Britain stands in 
no need of commendation. The work 
precisely meets the needs and wishes 
of the general practitioner. — The 
American Practitioner and News. 

Green's Pathology is the text-book 



of the day — as much so almost as 
Gray's Anatomy. It is fully up-to- 
date in the record of fact, and so pro- 
fusely illustrated as to give to each 
detail of text sufficient explanation. 
The work is an essential to the prac- 
titioner — whether as surgeon orphys- 
ician. It is the best of up-to date 
text-books. — Virginia Med. Monthly. 



GREENE (WILLIAM H.). A MANUAL OF MEDICAL CHEM- 
ISTRY. For the Use of Students. Based upon Bowman's Medical 
Chemistry. In one 12mo. vol. of 310 pages, with 74 illus. Cloth, $1.75. 

GROSS (SAMUEL D.). A PRACTICAL TREATISE ON THE DIS- 
EASES, INJURIES AND MALFORMATIONS OF THE URINARY 
BLADDER, THE PROSTATE GLAND AND THE URETHRA. 

Third edition, thoroughly revised and edited by Samuel W. Gross, 
M. D. In one octavo vol. of 574 pages, with 170 illus. Cloth, $4.50. 

HABERSHON (S. O.). ON THE DISEASES OF THE ABDOMEN, 

comprising those of the Stomach, Oesophagus, Caecum, Intestines 
and Peritoneum. Second American from the third English edition. 
In one octavo volume of 554 pages, with 11 engravings. Cloth, $3.50. 

HAMILTON (ALLAN MCLANE). NERVOUS DISEASES, THEIR 
DESCRIPTION AND TREATMENT. Second and revised edition. 
In one octavo volume of 598 pages, with 72 engravings. Cloth, $4. 

HAMILTON (FRANK H.). A PRACTICAL TREATISE ON FRAC- 
TURES AND DISLOCATIONS. Eighth edition, revised and edited 
by Stephen Smith, A. M., M. D. In one handsome octavo volume of 



832 pages, with 507 engravings. 

Its numerous editions are convin- 
cing proof of its value and popular- 
ity. It is preeminently the authority 
on fractures and dislocations. The 
additions it has received by its re- 



Cloth, $5.50 ; leather, $6.50. 
cent revision make it a work thor- 
oughly in accordance with rnodern 
practice theoretically, mechanically, 
aseptically. — Boston Medical and 
Surgical Journal. 



HARD A WAY (W. A.). MANUAL OF SKIN DISEASES. New (2d) 
edition. In one 12mo. volume of 560 pages, with 40 illustrations and 
2 plates. Cloth, $2.25, net. Just ready. 



HARE (HOBART AMORY). PRACTICAL DIAGNOSIS. THE 
USE OF SYMPTOMS IN THE DIAGNOSIS OF DISEASE. New 
(3d) edition. In one octavo volume of 615 pages, with 204 engravings 



and 13 full-page colored plates. 
It is unique in many respects, and 
the author has introduced radical 
changes which will be welcomed by 
all. Anyone who reads tbis book 
will become a more acute observer, 
will pay more attention to the simple 
yet indicative signs of disease, and 



Cloth, $4.75, net. Just ready. 
he will become a better diagnosti- 
cian. This is a companion to Prac- 
tical Therapeutics, by the same 
author, and it is difficult to conceive 
of any two works of greater practical 
utility. — Medical Review. 



Lea Brothers & Co., Philadelphia and New York. 13 



HARE (HOB ART AMORY). A TEXT-BOOK OF PRACTICAL 

THERAPEUTICS, with Special Reference to the Application of Reme- 
dial Measures to Disease and their Employment upon a Rational 
Basis. With articles on various subjects by well-known specialists. 
New (7th) and revised edition. In one octavo volume of 776 
Cloth, $3.75, net; leather, $4.50, net. Just ready. 



Its classifications are inimitable, 
and the readiness with which any- 
thing can be found is the most won- 
derful achievement of the art of in- 
dexing. This edition takes in all 
the latest discovered remedies. — 
The St. Louis Clinique. 

The great value of the work lies 
in the fact that precise indications 
for administration are given. A 
complete index of diseases and 
remedies makes it an easy reference 
work. It has been arranged so that 



it can be readily used in connection 
with Hare's Practical Diagnosis. 
For the needs of the student and 
general practitioner it has no equal. 
— Medical Sentinel. 

The best planned therapeutic work 
of the century. — American Prac- 
titioner and News. 

It is a book precisely adapted to- 
the needs of the busy practitioner, 
who can rely upon finding exactly 
what he needs. — The National Med- 
ical Review. 



HARE (HOBART AMORY, EDITOR). A SYSTEM OF PRAC- 
TICAL THERAPEUTICS. In a series of contributions by eminent 
practitioners. In four large octavo volumes comprising about 4500 
pages,with about 550 engravings. Vol. IV., just ready. For sale by sub 
scription only. Full prospectus free on application to the Publishers 
Regular price, Vol. IV., cloth, $6 ; leather, $7 ; half Russia, $8 
Price Vol. IV. to former or new subscribers to complete work, cloth 
$5 ; leather, $6; half Russia, $7. Complete work, cloth, $20; leather 
$24; half Russia, $28. 



The great value of Hare's System of Practical Therapeutics has led to a 
widespread demand for a new volume to represent advances in treatment 
made since the publication of the first three. More than fulfilling this 
request the Editor has secured contributions from practically a new corps 
of equally eminent authors, so that entirely fresh and original matter is 
ensured. The plan of the work, which proved so successful, has been fol- 
lowed in this new volume, which will be found to present the latest devel- 
opments and applications of this most practical branch of the medical art. 
Prescriptions indicative of the manner in which particular drugs are admin- 
istered are frequently inserted, with the aim of making the work as helpful 
as possible ; and especial care is devoted to such precision of detail as 
will render it a safe guide in the use of the newer and less familiar agents. 
This volume will therefore be indispensable to the many thousands of 
subscribers to the original work, and it will be of no less value by itself, 
since it reflects the whole position of each subject. The entire System is 
an unrivalled encyclopaedia on the practical parts of medicine, and merits 
the great success it has won for that reason. 



14 Lea Bbothees & Co., Philadelphia and New Yobk. 

HARTSHORNE (HENRY). ESSENTIALS OF THE PRINCIPLES 
AND PRACTICE OF MEDICINE. Fifth edition. In one 12mo. 
volume, 669 pages, with 144 engravings. Cloth, $2.75 ; half bound, $3. 



— A HANDBOOK OF ANATOMY AND PHYSIOLOGY. In one 
12mo. volume of 310 pages, with 220 engravings. Cloth, $1.75. 

— A CONSPECTUS OF THE MEDICAL SCIENCES. Comprising 
Manuals of Anatomy, Physiology, Chemistry, Materia Medica, Prac- 
tice of Medicine, Surgery and Obstetrics. Second edition. In one royal 
12mo. vol. of 1028 pages, with 477 illus. Cloth, $4.25 ; leather, $5. 



HAYDEN (JAMES R.). A MANUAL OF VENEREAL DISEASES. 

New (2d) edition. In one 12mo. volume of 304 pages, with 54 en- 
gravings. Cloth, $1.50, net. Just ready. 



It is practical, concise, definite 
and of sufficient fulness to be satis- 
factory. — Chicago Clinical Review. 

This work gives all of the prac- 
tically essential information about 
the three venereal diseases, gon- 
orrhoea, the chancroid and syphilis. 
In diagnosis and treatment it is par- 



ticularly thorough, and may be 
relied upon as a guide in the man- 
agement of this class of diseases. — 
Northwestern Lancet. 

It is well written, up to date, and 
will be found very useful. — Inter- 
national Medical Magazine. 



HAYEM (GEORGES) AND HARE (H. A.). PHYSICAL AND 
NATURAL THERAPEUTICS. The Remedial Use of Heat, Elec- 
tricity, Modifications of Atmospheric Pressure, Climates and Mineral 
Waters. Edited by Prof. H. A. Hare, M. D. In one octavo volume 
of 414 pages,with 113 engravings. Cloth, $3. 



This well-timed up-to-date volume 
is particularly adapted to the re- 
quirements of the general practi- 
tioner. The section on mineral 
waters is most scientific and prac- 
tical. Some 200 pages are given up 
to electricity and evidently embody 
the latest scientific information on 
the subject. Altogether this work 
is the clearest and most practical aid 
to the study of nature's therapeutics 
that has yet come under our obser- 
vation. — The Medical Fortnightly. 

For many diseases the most potent 
remedies lie outside of the materia 
medica, a fact yearly receiving wider 



recognition. Within this large 
range of applicability, physical 
agencies when compared with drugs 
are more direct and simple in their 
results. Medical literature has long 
been rich in treatises upon medical 
agents, but an authoritative work 
upon the other great branch of 
therapeutics has until now been a 
desideratum. The section on climate, 
rewritten by Prof. Hare, will, for 
the first time, place the abundant 
resources of our country at the in- 
telligent command of American 
practitioners. — The Kansas City 
Medical Index. 



HERMAN (G. ERNEST). FIRST LINES IN MIDWIFERY. In 

one 12mo. vol. of 198 pages, with 80 engravings. Cloth, $1.25. See 
Student's Series of Manuals, page 27. 



HERMANN (L.). EXPERIMENTAL PHARMACOLOGY. A Hand- 
book of the Methods for Determining the Physiological Actions of 
Drugs. Translated by Robert Meade Smith, M. D. In one 12mo. 
volume of 199 pages, with 32 engravings. Cloth, $1.50. 



Lea Bkothers & Co., Philadelphia and New Yoek. 15 



HERRICK (JAMES B.). A HANDBOOK OF DIAGNOSIS. In 

one handsome 12mo. volume of 429 pages, with 80 engravings and 2 
colored plates. Cloth, $2.50. 



Excellently arranged, practical, 
concise, up-to-date, and eminently 
well fitted for the use of the prac- 
titioner as well as of the student. — 
Chicago Med. Recorder. 

This volume accomplishes its ob- 
jects more thoroughly and com- 
pletely than any similar work yet 
published. Each section devoted to 
diseases of special systems is pre- 
ceded with an exposition of the 
methods of physical, chemical and 



microscopical examination to be em- 
ployed in each class. The technique 
of blood examination,including color 
analysis, is very clearly stated. 
Uranalysis receives adequate space 
and care. — New York Med. Journal. 
We commend the book not only to 
the undergraduate, but also to the 
physician who desires a ready means 
of refreshing his knowledge of diag- 
nosis in the exigencies of professional 
life. — Memphis Medical Monthly. 



TTTT.Ti (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS 
DISORDERS. In one 8vo. volume of 479 pages. Cloth, $3.25. 

HTLLJER (THOMAS). A HANDBOOK OF SKIN DISEASES. 
Second edition. In one royal 12mo. volume of 353 pages, with two 
plates. Cloth, $2.25. 

HIRST (BARTON C.) AND PBERSOL (GEORGE A.). HUMAN 

MONSTROSITIES. Magnificent folio, containing 220 pages of text 
and illustrated with 123 engravings and 39 large photographic plates 
from nature. In four parts, price each, $5. Limited edition. For sale 
by subscription only. 

HOBLYN (RICHARD D.). A DICTIONARY OF THE TEEMS 
USED IN MEDICINE AND THE COLLATERAL SCIENCES. 
In one 12mo. volume of 520 double-columned pages. Cloth, $1.50 ; 
leather, $2. 

HODGE (HUGH L.). ON DISEASES PECULIAR TO WOMEN, 
INCLUDING DISPLACEMENTS OF THE UTERUS. Second and 
revised edition. In one 8vo. vol. of 519 pp., with illus. Cloth, $4.50. 

HOFFMANN (FREDERICK) AND POWER (FREDERICK B.). 

A MANUAL OF CHEMICAL ANALYSIS, as Applied to the 
Examination of Medicinal Chemicals and their Preparations. Third 
edition, entirely rewritten and much enlarged. In one handsome octavo 
volume of 621 pages, with 179 engravings. Cloth, $4.25. 



HOL.DEN (LUTHER). LANDMARKS, MEDICAL AND SURGI- 
CAL. From the third English edition. With additions by W. W. 
Keen, M. D. In one royal 12mo. volume of 148 pages. Cloth, $1. 

HOLMES (TIMOTHY). A TREATISE ON SURGERY. Its Prin- 
ciples and Practice. A new American from the fifth English edition. 
Edited by T. Pickering Pick, F.R.C.S. In one handsome octavo vol- 
ume of 1008 j>ages, with 428 engravings. Cloth, $6 ; leather, $7. 



— A SYSTEM OF SURGERY. With notes and additions by various 
American authors. Edited by John H. Packard, M. D. In three 
very handsome 8vo. volumes containing 3137 double-columned pages, 
with 979 engravings and 13 lithographic plates. Per volume, cloth, $6 ; 
leather, $7 ; half Russia, $7.50. For sale by subscription only. 



16 Lea Beothers & Co., Philadelphia and New York. 



HORNER (WILLIAM E.). SPECIAL ANATOMY AND HIS- 
TOLOGY. Eighth edition, revised and modified. In two large 8vo. 
volumes of 1007 pages, containing 320 engravings. Cloth, $6. 

HUDSON (A.). LECTUKES ON THE STUDY OF FEVEE. In one 
octavo volume of 308 pages. Cloth, $2.50. 

HUTCHISON (ROBERT) AND RAINY (HARRY). CLINICAL 
METHODS. A GUIDE TO THE PRACTICAL STUDY OF 
MEDICINE. In one 12mo. volume of 562 pages, with 137 engrav- 
ings and 8 colored plates. Cloth, $3.00. Just ready. 

HUTCHINSON (JONATHAN). SYPHILIS. In one pocket-size 12mo. 
volume of 542 pages, with 8 chromo-lithographic plates. Cloth, $2.25. 
See Series of Clinical Manuals, p. 25. 



HYDE (JAMES NEVINS). A PRACTICAL TREATISE ON DIS- 
EASES OF THE SKIN. New (4th) edition, thoroughly revised. 
In one octavo volume of 815 pages, with 110 engravings and 12 full- 
page plates, 4 of which are colored. Cloth, $5.25 ; leather, $6.25. 



This edition has been carefully re- 
vised, and every real advance has 
been recognized. The work answers 
the needs of the general practitioner, 
the specialist, and the student, and 
is a happy example of the fact that 
such a wide range of adaptation can 
be given within the compass of a 
volume of convenient size and price. 
— The Ohio Med. Jour. 

A treatise of exceptional merit 
characterized by conscientious care 
and scientific accuracy. — Buffalo 
Med. Journal. 

Those who wish the latest views 
may confidently consult its pages. — 
University Med. Magazine. 

A complete exposition of our 
knowledge of cutaneous medicine as 
it exists to-day. The teaching in- 



culcated throughout is sound as well 
as practical. — The American Jour- 
nal of the Medical Sciences. 

It is the best one-volume work 
that we know. The student who 
gets this book will find it a useful 
investment, as it will well serve him 
when he goes into practice. — Vir- 
ginia Medical Semi-Monthly. 

A full and thoroughly modern 
text-book on dermatology. — The 
Pittsburg Medical Review. 

All new facts have been considered 
in detail, and in every way this book 
represents the Dermatology of to- 
day. It is the most practical hand- 
book on dermatology with which we 
are acquainted. — The Chicago Med- 
ical Recorder. 



JACKSON (GEORGE THOMAS). THE READY-REFERENCE 

HANDBOOK OF DISEASES OF THE SKIN. New (3d) edition. 
In one 12mo. volume of 610 pages, with 73 illustrations and a colored 
plate. In press. Notices of previous editions are appended. 



A prompt and ready source of 
knowledge on all points of termin- 
ology, symptoms, varieties, etiology, 
pathology, diagnosis, treatment and 
prognosis of dermal affections. Ta- 
bles of differential diagnosis and 
standard prescriptions will be found 
scattered through the text, and the 
work ends with an appendix of well- 
tried formulae. The series of illus- 
trations is rich and instructive. — 
Memphis Med. Monthly. 

The text is clear and sufficiently 
full. The subject of treatment in- 



cludes all the newer methods and 
remedies of proved value. It is a 
thoroughly satisfactory and clear 
expression of cutaneous diseases. — 
American Journal of the Medical 
Sciences. 

The work is fair and accurate, full 
and complete, and it embodies the 
recent additions to our information. 
Above all, it is eminently practical. 
The reviewer has found it a good 
book for students, and believes it is 
equally good for the practitioner. — 
Chicago Clinical Review. 



Lea Bkothers & Co., Philadelphia and New York. 17 



JAMEESON (W. AL.L.AN). DISEASES OF THE SKIN. Third 
edition. In one octavo volume of 656 pages, with 1 engraving and 9 
double-page chromo-lithographic plates. Cloth, $6. 

JEWETT (CHARLES). ESSENTIALS OF OBSTETRICS. In one 

12mo. volume of 356 pages, with 80 engravings and 3 colored plates. 
Cloth, $2.25. Just ready. 

ing it in attractive and easily tangi- 
ble form. The book is well illus- 
trated throughout. — Nashville Jour. 



An exceedingly useful manual for 
student and practitioner. The au- 
thor has succeeded unusually well 
in condensing the text and in arrang- j of Medicine and Surgery. 

THE PRACTICE OF OBSTETRICS. By American Authors. 

One large octavo volume of 763 pages, with 441 engravings in black 
and colors, and 22 full-page colored plates. Just ready. Cloth, 
$5.00, net; leather, $6.00, net. 

JONES (C. HANDFIELD). CLINICAL OBSERVATIONS ON 
FUNCTIONAL NERVOUS DISORDERS. Second American edi- 
tion. In one octavo volume of 340 pages. Cloth, $3.25. 

JULER (HENRY). A HANDBOOK OF OPHTHALMIC SCIENCE 
AND PRACTICE. Second edition. In one octavo volume of 549 
)ages, with 201 engravings, 17 chromo-lithographic plates, test-types of 
Taeger and Snellen, and Holmgren's Color-Blindness Test. Cloth, 
$5.50 ; leather, $6.50. 



J* 



The continuous approval mani- 
fested toward this work testifies to 
the success with which the author 
has produced concise descriptions 
and typical illustrations of all the 
important affections of the eye. The 
volume is particularly rich in mat- 
ter of practical value, such as direc- 
tions for diagnosing, use of instru- 
ments, testing for glasses, for color 
blindness, etc. The sections devoted 
to treatment are singularly full, and 



J at the same time concise, and couch- 
j in language that cannot fail to be 
understood. This edition likewise 
| embodies such revisions and changes 
I as were necessary to render it thor- 
I oughly representative, and moreover 
| it has been enriched by the addition 
of 100 pages and 75 engravings. All 
told, there are 201 engravings, ex- 
clusive of 17 handsomely colored. — 
The Medical Age. 



KING (A. F. A.). A MANUAL OF OBSTETRICS. Seventh edition. 
In one 12mo. volume of 573 pages, with 223 illustrations. Cloth, 
$2.50. 



The student world, particularly, 
seems thoroughly conversant with 
the merits of this manual, for there 
is certainly no work upon obstetrics 
more in demand by them. This 
edition has been thoroughly revised 
in an endeavor to represent recent 
advances in its subject, special at- 
tention being devoted to aseptic 
midwifery. The book is increased 
in size, and a number of illustra- 
tions has been added to its already 
rich store. — Memphis Med. Monthly. 



From first to finish it is thoroughly 
practical, concise in expression, well 
illustrated, and includes a statement 
of nearly every fact of importance 
discussed in obstetric treatises or 
cyclopedias. Its arrangement is 
progressive, which makes it most 
suitable for the class-room. The 
well arranged index renders the 
book useful to the practitioner who 
is in haste to refresh his memory. — 
Virginia Medical Semi- Monthly. 



KIRK (EDWARD C). OPERATIVE DENTISTRY. Handsome 
octavo of 700 pages, with 751 illustrations. Just ready. See American 
Text-Books of Dentistry, page 2. 



18 Lea Bkothers & Co., Philadelphia, and New Yoek. 

KLEIN (E.). ELEMENTS OF HISTOLOGY. New (5th) edition. In 
one 12mo. volume of 506 pages, with 296 engravings. Just ready. 
Cloth, $2.00, net. See Student's Series of Manuals, page 27. 

which it is written, the absence or 



It is the most complete and con- 
cise work of the kind that has yet 
emanated from the press, and is 
invaluable to the active as well as 
to the embryo practitioner. The 
illustrations are vastly superior to 
those in most works of its class. — 
The Medical Age. 

The clear and concise manner in 



debatable matter, and of conflicting 
views, the convenient size of the 
book and its moderate price, will 
account for its undoubted success. — 
Medical Chronicle. 

This work deservedly occupies a 
first place as a text-book on his- 
tology. — Canadian Practitioner. 



LANDIS (HENRY G.). THE MANAGEMENT OF LABOR. In one 

handsome 12mo. volume of 329 pages, with 28 illus. Cloth, $1.75. 

LA ROCHE (R.). YELLOW FEVER. In two 8vo. volumes of 1468 

pages. Cloth, $7. 



PNEUMONIA. In one 8vo. volume of 490 pages. Cloth, $3. 



LAURENCE (J. Z.) AND MOON (ROBERT C). A HANDY- 
BOOK OF OPHTHALMIC SURGERY. Second edition. In one 
octavo volume of 227 pages, with 66 engravings. Cloth, $2.75. 



LEA (HENRY C). A HISTORY OF AURICULAR CONFESSION 
AND INDULGENCES IN THE LATIN CHURCH. In three 
octavo volumes of about 500 pages each. Per volume, cloth, $3.00. 
Complete work just ready. 

CHAPTERS FROM THE RELIGIOUS HISTORY OF SPAIN; 

CENSORSHIP OF THE PRESS; MYSTICS AND ILLUMINATI- 
THE ENDEMONIADAS ; EL SANTO NINO DE LA GUARDIA ; 
BRIANDA DE BARDAXI. In one 12mo. volume of 522 pages. 
Cloth, $2.50. 

FORMULARY OF THE PAPAL PENITENTIARY. In one 



octavo volume of 221 pages, with frontispiece. Cloth, $2.50. 

SUPERSTITION AND FORCE ; ESSAYS ON THE WAGER 

OF LAW, THE WAGER OF BATTLE, THE ORDEAL AND 
TORTURE. Fourth edition, thoroughly revised. In one hand- 
some royal 12mo. volume of 629 pages. Cloth, $2.75. 

STUDIES IN CHURCH HISTORY. The Rise of the Temporal 

Power — Benefit of Clergy — Excommunication. New edition. In one 
handsome 12mo. volume of 605 pages. Cloth, $2.50. 

AN HISTORICAL SKETCH OF SACERDOTAL CELIBACY 

IN THE CHRISTIAN CHURCH. Second edition. In one hand- 
some octavo volume of 685 pages. Cloth, $4.50. 

LEE (HENRY) ON SYPHILIS. In one 8vo. volume of 246 pages. 
Cloth, $2.25. 

LEHMANN (C. G.). A MANUAL OF CHEMICAL PHYSIOLOGY. 
In one 8vo. volume of 327 pages, with 41 engravings. Cloth, $2.25. 



Lea Brothers & Co., Philadelphia and New "York. 19 

LOOMIS (ALFRED L.) AND THOMPSON (W. GILMAN, 

EDITORS). A SYSTEM OF PRACTICAL MEDICINE. In 

Contributions by Various American Authors. In four very hand- 
some octavo volumes of about 900 pages each, fully illustrated in 
in black and colors. Complete work now ready. Per volume, cloth, 
$5 ; leather, $6 ; half Morocco, $7. For sale by subscription only. 
Full prospectus free on application to the Publishers. See American 
System of Practical Medicine, page 2. 

LUFF (ARTHUR P.). MANUAL OF CHEMISTRY, for the use of 

Students of Medicine. In one 12mo. volume of 522 pages, with 36 
engravings. Cloth, $2. See Student's Series of Manuals, page 27. 



LYMAN (HENRY M.). THE PRACTICE OF MEDICINE. In one 

very handsome octavo volume of 925 pages, with 170 engravings. 
Cloth, $4.75 ; leather, $5.75. 



An excellent treatise on the prac- 
tice of medicine, written by one 
who is not only familiar with his 
subject, but who has also learned 
through practical experience in 
teaching what are the needs of the 
student and how to present the facts 
to his mind in the most readily 
assimilable form. The practical and 
busy physician, who wants to ascer- 
tain in a short time all the necessary 
facts concerning the pathology or 



treatment of any disease will find 
here a safe and convenient guide. — 
The Charlotte Medical Journal. 

Complete, concise, fully abreast oi 
the times and needed by all students 
and practitioners. — Univ. Med. Mag. 

An exceedin gly valuable text-book . 
Practical, systematic, complete and 
well balanced. — Chicago Med. Re- 
corder. 

Represents fully the most recent 
knowledge. — Montreal Med. Jour. 



LYONS (ROBERT D.). A TREATISE ON FEVER. In one octavo 
volume of 362 pages. Cloth, $2.25. 

MACKENZIE (JOHN NOLAND). ON THE NOSE AND THROAT. 

Handsome octavo, about 600 pages, richly illustrated. Preparing. 

MA1SCH (JOHN M.). A MANUAL OF ORGANIC MATERIA 
MEDICA. New (6th) edition, thoroughly revised by H. C. C. Maisch, 
Ph. G., Ph. D. In one very handsome 12mo. volume of 509 pages, with 
285 engravings. Cloth, $3. 



The best handbook upon phar- 
macognosy of any published in this 
country. — Boston Med. & Sur. Jour. 

Noted on both sides of the Atlantic 
and esteemed as much in Germany as 
in America. The work has no equal. 
— Dominion Med. Monthly. 

Used as text-book in every college 
of pharmacy in the United States 
and recommended in medical col- 
leges. — American Therapist. 



New matter has been added, and 
the whole work has received careful 
revision, so as to conform to the new 
United States Pharmacopoeia. — Vir- 
ginia Medical Monthly. 

This standard text-book is a 
work of such well-tried merit that it 
standsdn no danger of being super- 
seded. — Amer. Druggist and Pharm. 
Record. 



20 Lea Bbotheks & Co., Philadelphia and New York. 



MANUALS. See Student's Quiz Series, page 27, Student's Series of 
Manuals, page 27, and Series of Clinical Manuals, page 25. 

MARSH (HOWARD). DISEASES OF THE JOINTS. In one 12mo. 
volume of 468 pages, with 64 engravings and a colored plate. Cloth, $2. 
See Series of Clinical Manuals, page 25. 

MARTIN (EDWARD). A MANUAL OF SUEGICAL DIAGNOSIS. 
In one 12mo. volume of about 400 pp., fully illustrated. Preparing. 

MAY (C. H.). MANUAL OF THE DISEASES OF WOMEN. For 

the use of Students and Practitioners. Second edition, revised by L. 
S. Rau, M. D. In one 12mo. volume of 360 pages, with 31 engrav- 
ings. Cloth, $1.75. 

MEDICAL NEWS POCKET FORMULARY, see page 32. 

MITCHELL (S. WEIR). CLINICAL LESSONS ON NERVOUS 
DISEASES. In one 12mo. volume of 299 pages, with 19 engravings 
and 2 colored plates. Cloth, $2.50. Of the hundred numbered copies 
with the Author's signed title page a few remain ; these are offered 
in green cloth, gilt top, at $3.50, net. 

popular one. The book treats of 
hysteria, recurrent melancholia, dis- 
orders of sleep, choreic movements, 
false sensations of cold, ataxia, 
hemiplegic pain, treatment of sci- 
atica, erythromelalgia, reflex ocular 
neurosis, hysteric contractions, ro- 
tary movements in the feeble 
minded, etc. Few can speak with 
more authority than the author. — 
The Journal of the American Medi- 
cal Association. 



There is no question as to the in- 
terest of the clinical pictures pre- ' 
sented in this volume. Many rare 
examples of spurious troubles 
(hysteria) are given and irregular 
types of other " nervous " affections. 
The study of these types, from the 
author's clear notes and deductions, 
will be of value to the student of 
neurology. — The Chicago Clinical 
Review. 

This is a book by a master and if 
we mistake not it will prove a very 

MITCHELL (JOHN K.). REMOTE CONSEQUENCES OF IN- 
JURIES OF NERVES AND THEIR TREATMENT. In one 
handsome 12mo. volume of 239 pages, with 12 illustrations. Cloth, $1.75. 

Injuries of the nerves are of fre- 



quent occurrence m private practice 
and often the cause of intractable 
and painful conditions, conse- 
quently this volume is of especial 
interest. Doctor Mitchell has had 
access to hospital records for the last 
thirty years, as well as to the 



government documents, and has 
skilfully utilized his opportunities. 
This work will doubtless take a 
prominent place in medical litera- 
ture among the special monographs 
which throw light into obscure 
places and contribute to the advance 
of medical science. — The Med. Age. 



MORRIS (HENRY). SURGICAL DISEASES OF THE KIDNEY. 
In one 12mo. volume of 554 pages, with 40 engravings and 6 colored 
plates. Cloth, $2.25. See Series of Clinical Manuals, page 25. 

MORRIS (MALCOLM). DISEASES OF THE SKIN. New (2d) 
edition. In one 12mo. volume of 601 pages, with 10 chromo-litho- 
graphic plates and 26 engravings. Cloth, $3.25, net. Just ready. 

MULLER (J.). PRINCIPLES OF PHYSICS AND METEOROL- 
OGY. In one large 8vo. vol. of 623 pages, with 538 cuts. Cloth, $4.50. 



Lea Brothees & Co., Philadelphia and New York. 21 



MUSSER (JOHN H.). A PRACTICAL TREATISE ON MEDICAL 
DIAGNOSIS, for Students and Physicians. New (2d) edition, thor- 
oughly revised. In one octavo volume of 931 pages, with 177 engrav- 
ings and 11 full-page colored plates. Cloth, $5 ; leather, $6. 



We have no work of equal value 
in English. — University Medical 
Magazine. 

Every real advance that has been 
made in this rapidly progressing 
department of medicine is here re- 
corded. There is no half knowledge. 
His descriptions of the diagnostic 
manifestations of diseases are accu- 
rate. This work will meet all the 
requirements of student and physi- 
cian. — The Medical News. 

From its pages may be made the 
diagnosis of every malady that 
afflicts the human body, including 
those which in general are dealt 



with only by the specialist. The 
early demand for the new edition 
speaks volumes for the book's popu- 
larity. — Northwestern Lancet. 

It so thoroughly meets the precise 
demands incident to modern research 
that it has been already adopted as a 
leading text-book by the medical 
colleges of this country. — North 
American Practitioner. 

Occupies the foremost place as a 
thorough, systematic treatise. — Ohio 
Medical Journal. 

The best of its kind, invaluable to 
the student, general practitioner and 
teacher. — Montreal Medical Journal. 



NATIONAL. DISPENSATORY. See Stille, Maisch & Caspari, p. 27. 

NATIONAL FORMULARY. See Stille, Maisch & Caspari' s National 
Dispensatory, page 27. 

NATIONAL MEDICAL DICTIONARY. See Billings, page 4. 



NETTLESHD? (E.). DISEASES OF THE EYE. New (5th) American 
from sixth English edition, thoroughly revised. In one 12mo. volume 
of 521 pages, with 161 engravings, and 2 colored plates, test-types, 
formulae and color-blindness test. Cloth, $2.25. Just ready. 



By far the best student's text-book 
on the subject of ophthalmology and 
is conveniently and concisely ar- 
ranged. — The Clinical Review. 

It has been conceded by ophthal- 
mologists generally that this work 
for compactness, practicality and 
clearness has no superior in the 



English language. — Journal of 
Medicine and Science. 

The present edition is the result 
of revision both in England and 
America, and therefore contains the 
latest and best ophthalmological 
ideas of both continents. — The Phy- 
sician and Surgeon. 



NORRIS (WM. F.) AND OLIVER (CHAS. A.). TEXT-BOOK OF 
OPHTHALMOLOGY. In one octavo volume of 641 pages, with 357 
engravings and 5 colored plates. Cloth, $5 ; leather, $6. 



to the every-day student and the 
scientific observer is offered to the 
reader. Rules and procedures are 
made so plain and so evident, that 



We take pleasure in commending 
the " Text-book " to students and 
practitioners as a safe and admir- 
able guide, well qualified to furnish 

them, as the authors intended it any student can easily understand 
should, with " a working knowl- \ and employ them. It is practical in 
edge of ophthalmology." — Johns its teachings. We unreservedly en- 
Hopkins Hospital Bulletin. dorse it as the best, the safest and the 

The first text-book of diseases of j most comprehensive volume upon 
the eye written by American authors , the subject that has ever been offered 

for American colleges and students, to the American medical public. 

Every method of ocular precision , Annals of Ophthalmology and Oto- 
that can be of any clinical advantage logy. 



Lea Beothebs & Co., Philadelphia and New Yoek. 



OWEN (EDMUND). SURGICAL DISEASES OF CHILDREN. 

In one 12mo. volume of 525 pages, with 85 engravings and 4 colored 
plates. Cloth, $2. See Series of Clinical Manuals, page 25. 



PARK (ROSWELL). A TREATISE ON SURGERY BY AMERI- 
CAN AUTHORS. In two handsome octavo volumes. Volume I., 
General Surgery, 799 pages, with 356 engravings and 21 full-page 
plates, in colors and monochrome. Volume II., Special Surgery, 
800 pages, with 430 engravings and 17 full-page plates, in colors 
and monochrome. Per volume, cloth, $4.50; leather, $5.50. Net. 
Complete work now ready. 



The work is fresh, clear and practi- 
cal, covering the ground thoroughly 
yet briefly, and well arranged for 
rapid reference, so that it will be of 
special value to the student and busy 
practitioner. The pathology is 
broad, clear and scientific, while the 
suggestions upon treatment are 
clear-cut, thoroughly modern and 
admirably resourceful. — Johns Hop- 
kins Hospital Bulletin. 

The latest and best work written 
upon the science and art of surgery. 
Columbus Medical Journal. 

Its special field of application is 
in practical, every-day use. It well 
deserves a place in every medical 
man's library. — The Pittsburg Med- 
ical Review. 

The illustrations are almost en- 



tirely new and executed in such a 
way that they add great force to the 
text. It gives us unusual pleasure 
to recommend this work to students 
and practitioners alike. — The Chi- 
cago Medical Recorder. 

The various writers have em- 
bodied the teachings accepted at 
the present hour and the methods 
now in vogue, both as regards 
causes and treatment. — The North 
American Practitioner. 

Both for the student and practi- 
tioner it is most valuable. It is 
thoroughly practical and yet thor- 
oughly scientific. — Medical News. 

A truly modern surgery, not only 
in pathology, but also in sound 
surgical therapeutics. — New Or- 
leans Med. and Surgical Journal. 



PARRY (JOHN S.). EXTRA-UTERINE PREGNANCY, ITS 
CLINICAL HISTORY, DIAGNOSIS, PROGNOSIS AND TREAT- 
MENT. In one octavo volume of 272 pages. Cloth, $2.50. 



PARVIN (THEOPHHjUS). THE SCIENCE AND ART OF OB- 
STETRICS. Third edition. In one handsome octavo volume of 
677 pages, with 267 engravings and 2 colored plates. Cloth, $4.25 ; 
leather, $5.25. 



In the foremost rank among the 
most practical and scientific medical 
works of the day. — Medical News. 

It ranks second to none in the 
English language. — Annals of Gyne- 
cology and Pediatry. 

The book is complete in every de- 
partment, and contains all the neces- 
sary detail required by the modern 
practising obstetrician. — Interna- 
tional Medical Magazine. 

In breadth and scope the work is 
adapted to the needs of the advanced 
scholar and specialist. The con- 



sideration of every subject is in 
reality brought up to the hour when 
the copy went to print. — Medicine. 

Parvin's work is practical, con- 
cise and comprehensive. We com- 
mend it as first of its class in the 
English language. — Medical Fort- 
nightly. 

Parvin's classical work now oc- 
cupies the front rank of modern 
text-books. It is an admirable text- 
book in every sense of the word. — 
Nashville Journal of Medicine and 
Surgery. 



Lea Beothees & Co., Philadelphia and New Yoek. 23 



PAYNE (JOSEPH FRANK). A MANUAL OF GENERAL 
PATHOLOGY. Designed as an Introduction to the Practice of Medi- 
cine. In one octavo volume of 524 pages, with 153 engravings and 
.1 colored plate. 

PEPPER'S SYSTEM OF MEDICINE. See page 3. 

PEPPER (A. J.). FORENSIC MEDICINE. In press. See Student's 

Series of Manuals, page 27. 
SURGICAL PATHOLOGY. In one 12mo. volume of 511 pages, 

with 81 engravings. Cloth, $2. See Student's Series of Manuals, p. 27. 

PICK (T. PICKERING). FRACTURES AND DISLOCATIONS. 
In one 12mo. volume of 530 pages, with 93 engravings. Cloth, $2. 
See Series of Clinical Manuals, page 25. 

PL.AYFAIR (W. S.). A TREATISE ON THE SCIENCE AND 
PRACTICE OF MIDWIFERY. Seventh American from the ninth 
English edition. In one octavo volume of 700 pages, with 207 
engravings and 7 plates. Cloth, $3.75 net ; leather, $4.75, net. Just 
ready. 

In the numerous editions which 
have appeared it has been kept con- 
stantly in the foremost rank. It is 
a work which can he conscientiously 
recommended to the profession. — 
The Albany Medical Annals. 



obstetrician. It holds a place among 
the ablest English-speaking authori- 
ties on the obstetric art. — Buffalo 
Medical and Surgical Journal. 

An epitome of the science and 
practice of midwifery, which em- 
This work must occupy a fore- j bodies all recent advances. — The 
most place in obstetric medicine as Medical Fortnightly. 
a safe guide to both student and ' 



THE SYSTEMATIC TREATMENT OF NERVE PROSTRA- 
TION AND HYSTERIA. In one 12mo. volume of 97 pages. 
Cloth, $1. 

POCKET FORMULARY, see page 32. 

POMTZER (ADAM). A TEXT-BOOK OF THE DISEASES OF THE 
EAR AND ADJACENT ORGANS. Second American from the 
third German edition. Translated by Oscae Dodd, M. D., and 
edited by Sie William Dalby, F. R. C. S. In one octavo volume of 
748 pages, with 330 original engravings. Cloth, $5.50. 

ment are clear and reliable. We 



The anatomy and physiology of 
each part of the organ of hearing 
are carefully considered, and then 
follows an enumeration of the dis- 
eases to which that special part of 
the auditory apparatus is especially 



can confidently recommend it, for it 
contains all tbat is known upon the 
subject. — London Lancet. 

A safe and elaborate guide into 
every part of otology. — American 



liable. The indications for treat- < Journal of the Medical Sciences. 

POWER (HENRY). HUMAN PHYSIOLOGY. Second edition. In 
one 12mo. volume of 396 pages, with 47 engravings. Cloth, $1.50. 
See Student's Series of Manuals, page 27. 

PROGRESSIVE MEDICINE, see page 32. 

PURDY (CHARLES W.). BRIGHT'S DISEASE AND ALLIED 
AFFECTIONS OF THE KIDNEY. In one octavo volume of 288 
pages, with 18 engravings. Cloth, $2. 



24 Lea Brothees & Co., Philadelphia and New York. 



PYE-SMITH (PHILIP H.). DISEASES OF THE SKIN. In one 

12mo. vol. of 407 pp., with 28 illus., 18 of which are colored. Cloth, $2. 

QUIZ SERIES. See Student's Quiz Series, page 27. 

RALFE (CHARLES H.). CLINICAL CHEMISTRY. In one 

12mo. volume of 314 pages, with 16 engravings. Cloth, $1.50. See 
Student's Series of Manuals, page 27. 

RAMSBOTHAM (FRANCIS H.). THE PRINCIPLES AND PRAC- 
TICE OF OBSTETRIC MEDICINE AND SURGERY. In one 

imperial octavo volume of 640 pages, with 64 plates and numerous 
engravings in the text. Strongly bound in leather, $7. 

REICHERT (EDWARD T.). A TEXT-BOOK ON PHYSIOLOGY. 

In one handsome octavo volume of about 800 pages, richly illustrated. 
Preparing. 

REMSEN (IRA). THE PRINCIPLES OF THEORETICAL CHEM- 
ISTRY. New (5th) edition, thoroughlv revised. In one 12mo. vol- 
ume of 326 pages. Cloth, $2. 



A clear and concise explanation 
of a difficult subject. We cordially 
recommend it. — The London Lancet. 

The book is equally adapted to the 
student of chemistry or the practi- 
tioner who desires to broaden his 
theoretical knowledge of chemistry. 
— New Orleans Med. and Surg. Jour. 

The appearance of a fifth edition 
of this treatise is in itself a guarantee 



that the work has met with general 
favor. This is further established 
by the fact that it has been trans- 
lated into German and Italian. The 
treatise is especially adapted to the 
laboratory student. It ranks unusu- 
ally high among the works of this 
class. This edition has been brought 
fully up to the times. — American 
Medico- Surgical Bulletin. 



RICHARDSON (BENJAMIN WARD). PREVENTIVE MEDI- 
CINE. In one octavo volume of 729 pages. Cloth, $4 ; leather, $5. 

ROBERTS (JOHN B.). THE PRINCIPLES AND PRACTICE OF 

MODERN SURGERY. In one octavo volume of 780 pages, with 
501 engravings. Cloth, $4.50 ; leather, $5.50. 



THE COMPEND OF ANATOMY. For use in the Dissecting 

Room and in preparing for Examinations. In one 16mo. volume of 
196 pages. Limp cloth, 75 cents. 

ROBERTS (SIR WILLIAM). A PRACTICAL TREATISE ON 
URINARY AND RENAL DISEASES, INCLUDING URINARY 
DEPOSITS. Fourth American from the fourth London edition. In 
one very handsome 8vo. vol. of 609 pp., with 81 illus. Cloth, $3.50. 

ROBERTSON (J. MCGREGOR). PHYSIOLOGICAL PHYSICS. 
In one 12mo. volume of 537 pages, with 219 engravings. Cloth, $2. 
See Student's Series of Manuals, page 27. 

ROSS (JAMES). A HANDBOOK OF THE DISEASES OF THE 
NERVOUS SYSTEM. In one handsome octavo volume of 726 pages, 
with 184 engravings. Cloth, $4.50 ; leather, $5.50. 



SAVAGE (GEORGE H.). INSANITY AND ALLIED NEUROSES, 
PRACTICAL AND CLINICAL. In one 12mo. volume of 551 pages, 
with 18 typical engravings. Cloth, $2. See Series of Clinical Man- 
uals, page 25. 



Lea Brothers & Co., Philadelphia and New York. 25 

SOHAFER (EDWARD A.). THE ESSENTIALS OF HISTOL- 
OGY, DESCRIPTIVE AND PRACTICAL. For the use of Students. 
New (5th) edition. In one handsome octavo volume of 359 pages, 
with 392 illustrations. Cloth, $3.00, net. Just ready. 
Nowhere else will the same very j The most satisfactory elementary 

moderate outlay secure as thoroughly text-book of histology in the Eng- 

useful and interesting an atlas of lish language. — The Boston Med. and 

structural anatomy. — The American Sur. Jour. 

Journal of the Medical Sciences. 

A COURSE OF PRACTICAL HISTOLOGY. New (2d) edition. 



In one 12mo. volume of 307 pages, with 59 engravings. Cloth, $2.25. 

The book very nearly approaches ] overpraised. It bears eloquent tes- 

perfection. Methods are given with timony to the wide knowledge and 

an accuracy of detail and prevision untiring industry of its author. — 

of difficulties which can hardly be | The Scottish died, and Surg. Jour. 

SCHMITZ AND ZUMPT'S CLASSICAL SERIES. Advanced 

Latin Exercises. Cloth, 60 cts. Schmidt's Elementary Latin Exer- 
cises. Cloth, 50 cents. Sallust. Cloth, 60 cents. Nepos. Cloth, 60 
cents. Virgil. Cloth, 85 cents. Curtius. Cloth, 80 cents. 

SCHOFLELD (ALFRED T.). ELEMENTARY PHYSIOLOGY 

FOR STUDENTS. In one 12mo. volume of 380 pages, with 227 
engravings and 2 colored plates. Cloth, $2. 

SCHRED3ER (JOSEPH). A MANUAL OF TREATMENT BY 
MASSAGE AND METHODICAL MUSCLE EXERCISE. Trans- 
lated by Walter Mendelson, M. D., of New York. In one hand- 
some octavo volume of 274 pages, with 117 fine engravings. 

SENN (NICHOLAS). SURGICAL BACTERIOLOGY. Second edi- 
tion. In one octavo volume of 268 pages, with 13 plates, 10 of which 
are colored, and 9 engravings. Cloth, $2. 

SERIES OF CLINICAL MANUALS. A Series of Authoritative 
Monographs on Important Clinical Subjects, in 12mo. volumes of about 
550 pages, well illustrated. The following volumes are now ready : 
Broadbent on the Pulse, $1.75; Yeo on Food in Health and Disease, 
new (2d) edition, $2.50; Carter and Frost's Ophthalmic Surgery, 
$2.25; Hutchinson on Syphilis, $2.25; Marsh on Diseases of the 
Joints, $2 ; Morris on Surgical Diseases of the Kidney, $2.25 ; Owen 
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locations, $2; Butlin on the Tongue, $3.50 ; Savage on Insanity and 
Allied Neuroses, $2. The following is in press: Lucas on Diseases 
of the Urethra. 
For separate notices, see under various authors' names. 

SERDES OF STUDENT'S MANUALS. See page 27. 

SIMON (CHARLES E.). CLINICAL DIAGNOSIS, BY MICRO- 
SCOPICAL AND CHEMICAL METHODS. New (2d) edition. In 
one very handsome octavo volume of 530 pages, with 135 engravings 
and 14 full-page colored plates. Cloth, $3.50. Just ready. 

This book thoroughly deserves its In all respects entirely up to date, 
success. It is a very complete, authen- — Medical Record. 
tic and useful manual of the micro- The chapter on examination of 
scopical and chemical methods the urine is the most complete and 
which are employed in diagnosis. i advanced that we know of in the 
Very excellent colored plates illus- ! English language.— Can adi an Prac- 
trate this work,— iVew; York Medical titioner. 
Journal, 



26 Lea Brothers & Co., Philadelphia and New York. 



SIMON (W.). MANUAL OF CHEMISTRY. A Guide to Lectures 
and Laboratory Work for Beginners in Chemistry. A Text-book 
specially adapted for Students of Pharmacy and Medicine. New (6th) 
edition. In one 8vo, volume of 536 pages, with 46 engravings and 8 
plates showing colors of 64 tests. Cloth, $3.00, net. Just ready. 

It is difficult to see how a better i the covers of this book. — The North- 
book could be constructed. No man j western Lancet. 
who devotes himself to the practice i Its statements are all clear and its 
of medicine need know more about teachings are practical. — Virginia 
chemistry than is contained between | Med. Monthly. 

SLADE (D. D.). DIPHTHERIA; ITS NATURE AND TREAT- 
MENT. Second edition. In one royal 12mo. vol., 158 pp. Cloth, $1.25. 

SMITH (EDWARD). CONSUMPTION ; ITS EARLY AND REME- 
DIABLE STAGES. In one 8vo. volume of 253 pp. Cloth, $2.25. 

SMITH (J. LEWIS). A TREATISE ON THE DISEASES OF IN- 
FANCY AND CHILDHOOD. Eighth edition, thoroughly revised 
and rewritten and much enlarged. In one large 8vo. volume of 983 
pages, with 273 engravings and 4 full-page plates. Cloth, $4.50; 
leather, $5.50. 
The most complete and satisfac- ] can more than hold its own against 
tory text-book with which we are any other work treating of the same 
acquainted. — American Gynecologi- j subject. — American Medico-Surgical 
cal and Obstetrical Journal. Bulletin. 

It truly is the most evenly bal- | A safe guide for students and phy- 
anced, clear in description and sicians. — The Am. Jour, of Obstetrics. 
thorough in detail of any of the For years the leading text-book on 
books published in this country on | children's diseases in America. — 
this subject. — Medical Fortnightly. . Chicago Medical Recorder. 
A treatise which in every respect I 

SMITH (STEPHEN). OPERATIVE SURGERY. Second and thor- 
oughly revised edition. In one octavo volume of 892 pages, with 
1005 engravings. Cloth, $4 ; leather, $5. 



One of the most satisfactory works 
on modern operative surgery yet 
published. The book is a compen- 



dium for the modern surgeon. — Bos- 
ton Medical and Surgical Journal. 



SOLLY (S. EDWIN). A HANDBOOK OF MEDICAL CLIMA- 
TOLOGY. In one handsome octavo volume of 462 pages, with en- 
gravings and 11 full-page plates, 5 of which are in colors. Cloth, $4.00. 
Just ready. 



A clear and lucid summary of 
what is known of climate in relation 
to its influence upon human beings. 
— The Therapeutic Gazette. 

The book is admirably planned, 
clearly written, and the author speaks 
from an experience of thirty years as 



an accurate observer and practical 
therapeutist. — Maryland Med. Jour. 
Every practitioner of medicine 
should possess himself of a copy and 
study it, and we are sure he will 
never regret it. — St. Louis Medical 
and Surgical Journal. 



STILLE (ALFRED). CHOLERA; ITS ORIGIN, HISTORY, CAUS- 
ATION, SYMPTOMS, LESIONS, PREVENTION AND TREAT- 
MENT. In one 12mo. volume of 163 pages, with a chart showing 
routes of previous epidemics. Cloth, $1.25. 

THERAPEUTICS AND MATERIA MEDICA. Fourth and 

revised edition. In two octavo volumes, containing 1936 pages. 
Cloth, $10; leather, $12. 



Lea Bkothees & Co., Philadelphia and New York. 27 



STLLLE ( ALFRED), MAISCH (JOHN M.) AND CASPARI 
(CHAS. JR.)- THE NATIONAL DISPENSATORY: Containing 
the Natural History, Chemistry, Pharmacy, Actions and Uses of 
Medicines, including those recognized in the latest Pharmacopoeias of 
the United States, Great Britain and Germany, with numerous refer- 
ences to the French Codex. Fifth edition, revised and enlarged, 
including the new U. S. Pharmacopoeia, Seventh Decennial Revision. 
With Supplement containing the new edition of the National Formu- 
lary. In one magnificent imperial octavo volume of about 2025 pages, 
with 320 engravings. Cloth, $7.25; leather, $8. With ready reference 
Thumb-letter Index. Cloth, $7.75 ; leather, $8.50. 



Recommended most highly for the 
physician, and invaluable to the 
druggist. — Therapeutic Gazette. 

It is the official guide for the Med- 
ical and Pharmaceutical professions. 
— Buffalo Med. and Sur. Jour. 

The readiness with which the vast 



amount of information contained in 
this work is made available is indi- 
cated by the twenty-five thousand 
references in the two indexes. — Bos- 
ton Medical and Surgical Journal. 
Should be recognized as a national 
standard. — North Am. Practitioner. 



STIMSON (LEWIS A.). A MANUAL OF OPERATIVE SURGERY. 

New (3d) edition. In one royal 12mo. volume of 614 pages, with 306 
engravings. Cloth, $3.75. 



A useful and practical guide for 
all students and practitioners. — Am. 
Journal of the Medical Sciences. 



The book is worth the price for the 
illustrations alone. — Ohio Medical 
Journal. 



STIMSON (LEWIS A.). A TREATISE ON FRACTURES AND 

DISLOCATIONS. In one handsome octavo volume of about 850 
pages, with 326 engravings and 22 plates. In press. 

STUDENT'S QUIZ SERD3S. A New Series of Manuals in question and 
answer for Students and Practitioners, covering the essentials of medical 
science. Thirteen volumes, pocket size, convenient, authoritative, 
well illustrated, handsomely bound in limp cloth, and issued at a low 
price. 1. Anatomy (double number); 2. Physiology; 3. Chemistry and 
Physics ; 4. Histology, Pathology and Bacteriology ; 5. Materia Medica 
and Therapeutics; 6. Practice of Medicine; 7. Surgery (double num- 
ber); 8. Genito-Urinary and Venereal Diseases; 9. Diseases of the Skin; 
10. Diseases of the Eye, Ear, Throat and Nose; 11. Obstetrics; 12. 
Gynecology ; 13. Diseases of Children. Price, $1 each, except Nos. 
1 and 7, Anatomy and Surgery, which being double numbers are priced 
at $1.75 each. Full specimen circular on application to publishers. 



STUDENT'S SERIES OF MANUALS. A Series of Fifteen Man- 
uals by Eminent Teachers or Examiners. The volumes are pocket-size 
12mos. of from 300-540 pages, profusely illustrated, and bound in red 
limp cloth. The following volumes may now be announced : Her- 
man's First Lines in Midwifery, $1.25 ; Luff's Manual of Chemistry, 
$2; Bruce's Materia Medica and Therapeutics (sixth edition), shortly ; 
Bell's Comparative Anatomy and Physiology, $2 ; Robert- 
son's Physiological Physics, $2; Gould's Surgical Diagnosis, $2; 
Klein's Elements of Histology (5tb edition), $2.00, net ; Pepper's 
Surgical Pathology, $2; Treves' Surgical Applied Anatomy, $2; 
Power's Human Physiology (2d edition), $1.50; Ralfe's Clinical, 
Chemistry, $1.50 ; and Clarke and Lock wood's Dissector's Manual 
$1.50. The following is in press : Pepper's Forensic Medicine. 
For separate notices, see under various author's names. 



28 Lea Brothers & Co., Philadelphia and New York. 



STURGES (OCTAVIUS). AN INTRODUCTION TO THE STUDY 
OF CLINICAL MEDICINE. In one 12mo. volume. Cloth, $1.25. 

SUTTON (JOHN BLAND). SURGICAL DISEASES OF THE 
OVARIES AND FALLOPIAN TUBES. Including Abdominal 
Pregnancy. In one 12mo. volume of 513 pages, with 119 engravings 
and 5 colored plates. Cloth, $3. 

TUMORS, INNOCENT AND MALIGNANT. Their Clinical 



Features and Appropriate Treatment. In one 8vo. vol. of 526 pp., with 
250 engravings and 9 full-page plates. Cloth, $4.50. Just ready. 

TAIT (LAWSON). DISEASES OF WOMEN AND ABDOMINAL 
SURGERY. In two handsome octavo volumes. Vol. I. contains 546 
pages and 3 plates. Cloth, $3. Vol. II., preparing. 

TANNER (THOMAS HAWKES) ON THE SIGNS AND DIS- 
EASES OF PREGNANCY. From the second English edition. In 
one octavo volume of 490 pages, with 4 colored plates and 16 engrav- 
ings. Cloth, $4.25. 



TAYLOR (ALFRED S.). MEDICAL JURISPRUDENCE. New 
American from the twelfth English edition, specially revised by Clark 
Bell, Esq., of the N. Y. Bar. In one 8vo. vol. of 831 pages, with 54 
engrs. and 8 full-page plates. Cloth, $4.50; leather, $5.50 Just ready. 



To the student, as to the physician, 
we would say, get Taylor first, and 
then add as means and inclination 
enable you. — American Practitioner 
and News. 

It is the authority accepted as 
final by the courts of all English- 
speaking countries. This is the im- 
portant consideration for medical 
men, since in the event of their 
being summoned as experts or wit- 



nesses, it strongly behooves them to 
be prepared according to the princi- 
ples and practice everywhere ac- 
cepted. The work will be found to 
be thorough, authoritative and 
modern. — Albany Law Journal. 

Probably the best work on the 
subject written in the English lan- 
guage. The work has been thor- 
oughly revised and is up to date. — 
Pacific Medical Journal. 

ON POISONS IN RELATION TO MEDICINE AND MEDI- 
CAL JURISPRUDENCE. Third American from the third London 
edition. In one octavo volume of 788 pages, with 104 illustrations. 
Cloth, $5.50 ; leather, $6.50. 

TAYLOR (ROBERT W.). THE PATHOLOGY AND TREAT- 
MENT OF VENEREAL DISEASES. In one very handsome octavo 
volume of 1002 pages, with 230 engravings and 7 colored plates. 
Cloth, $5.00 ; leather, $6.00. {Net.) 



By long odds the best work on 
venereal diseases. — Louisville Medi- 
cal Monthly. 

In the observation and treatment 
of venereal diseases his experience 
has been greater probably than that 
of any other practitioner of this con- 
tinent. — New York Medical Journal. 

The clearest, most unbiased and 
ably presented treatise as yet pub- 
lished on this vast subject. — The 
Medical News. 

Decidedly the most important and 
authoritative treatise on venereal 



diseases that has in recent years ap- 
peared in English. — American Jour- 
nal of the Medical Sciences. 

It is a veritable storehouse of our 
knowledge of the venereal diseases. 
It is commended as a conservative, 
practical, full exposition of the 
greatest value. — Chicago Clinical 
Review. 

The best work on venereal dis- 
eases in the English language. It 
is certainly above everything of the 
kind. — The St. Louis Medical and 
Surgical Journal. 



Lea Brothers & Co., Philadelphia and New York. 29 

TAYLOR (ROBERT W.). A PRACTICAL TREATISE ON SEX- 
UAL DISORDERS IN THE MALE AND FEMALE. In one 
8vo. vol. of 448 pp., with 73 engravings and 8 colored plates. Cloth, 
$3. Net. Just ready. 

It is a timely boon to the medical the female is presented in an exhaus- 
profession that an observer of Dr. j tive manner, all of the causes pro- 
Taylor's skill and experience has ' during it being described. The 
written a work on this hitherto author has presented to the profes- 
neglected and little understood class sion the ablest and most scientific 
of diseases which places them on a work as yet published on sexual 
scientific basis and renders them so t disorders, and one which, if carefully 
clear that the physician who reads f followed, will be of unlimited value 
its pages can treat this class of to both physician and patient. — 
patients intelligently. Sterility in I Ifedical Neivs. 

A CLINICAL ATLAS OF VENEREAL AND SKIN DISEASES. 



Including Diagnosis, Prognosis and Treatment. In eight large folio 
parts, measuring 14 x 18 inches, and comprising 213 beautiful figures 
on 58 full-page chromo-lithographic plates, 85 fine engravings and 425 
pages of text. Complete work now ready. Price per part, sewed in 
heavy embossed paper, $2.50. Bound in one volume, half Russia, 
$27 ; half Turkey Morocco, $28. For sale by subscription only. Address 
the publishers. Specimen plates by mail on receipt of ten cents. 

TAYLOR (SEYMOUR). INDEX OF MEDICINE. A Manual for 

the use of Senior Students and others. In one large 12mo. volume of 
802 pages. Cloth, $3.75. 

THOMAS (T. GAELLARD) AND MUNDE (PAUL F.). A PRAC 

TICAL TREATISE ON THE DISEASES OF WOMEN. Sixth 

edition, thoroughly revised by Paul F. Mtjsde, M. D. In one 

large and handsome octavo volume of 824 pages, with 347 engravings. 

Cloth, $5 ; leather, $6. 

The best practical treatise on the i This work, which has already gone 

subject in the English language. I through five large editions, and has 

It will be of especial value to the ' been translated into French, Ger- 

general practitioner as well as to the : man, Spanish and Italian, is the 

specialist. The illustrations are very most practical and at the same time 

satisfactory. Many of them are new the most complete treatise upon the 

and are particularly clear and attrac- subject. — The Archives of Gynecol- 

tive. — Boston Med . and Sur. Jour. ogy, Obstetrics and Pediatrics. 

THOMPSON (SLR HENRY). CLINICAL LECTURES ON DIS- 
EASES OF THE URINARY ORGANS. Second and revised edi- 
tion. In one octavo vol. of 203 pp., with 25 engravings. Cloth, $2.25. 

THE PATHOLOGY AND TREATMENT OF STRICTURE 

OF THE URETHRA AND URINARY FISTULA. From the 
third English edition. In one octavo volume of 359 pages, with 47 
engravings and 3 lithographic plates. Cloth, $3.50. 

THOMSON (JOHN). DISEASES OF CHILDREN. In one crown 
octavo volume of 350 pages, with 52 illus. Cloth, $1.75, net. Just ready. 

TODD (ROBERT BENTLEY). CLINICAL LECTURES ON CER- 
TAIN ACUTE DISEASES. In one 8vo. vol. of 320 pp., cloth, $2.50. 

TREVES (FREDERICK). OPERATIVE SURGERY. In two 

8vo. vols, containing 1550 pp., with 422 illus. Cloth, $9 ; leath., $11. 

A SYSTEM OF SURGERY. In Contributions by Twenty-five 

English Surgeons. In two large octavo volumes. Vol. I., 1178 pages, 
with 463 engravings and 2 colored plates. Vol. II., 1120 pages, with 
487 engravings and 2 colored plates. Price per volume, cloth, $8. 
Complete Work now ready. 



30 Lea Brothees & Co., Philadelphia and New York. 



TREVES (FREDERICK). THE STUDENTS' HANDBOOK OF 
SURGICAL OPERATIONS. In one 12mo. volume of 508 pp., with 
94 illustrations. Cloth, $2.50. 



— SURGICAL APPLIED ANATOMY. In one 12mo. vol. of 540 pp., 
with 61 engravings. Cloth, $2. See Student's Series of Manuals, p. 27. 



TUKE (DANIEL HACK). THE INFLUENCE OF THE MIND 
UPON THE BODY IN HEALTH AND DISEASE. Second edition. 
In one 8vo. volume of 467 pages, with 2 colored plates. Cloth, $3. 



VAUGHAN (VICTOR C.) AND NOVY (FREDERICK G.). 

PTOMAINS, LEUCOMAINS, TOXINS AND ANTITOXINS, 

or the Chemical Factors in the Causation of Disease. New (3d) edition. 
In one 12mo. volume of 603 pages. Cloth, $3. 

The work has been brought down 



to date, and will be found entirely 
satisfactory. — Journal of the Ameri- 
can Medical Association. 

The most exhaustive and most re- 
cent presentation of the subject. — 
American Jour, of the Med. Sciences. 



The present edition has been not 
only thoroughly revised throughout 
but also greatly enlarged, ample 
consideration being given to the new 
subjects of toxins and antitoxins. — 
Tri-State Medical Journal. 



VISITING LIST. THE MEDICAL NEWS VISITING LIST for 1899. 
Four styles : Weekly (dated for 30 patients); Monthly (undated for 
120 patients per month) ; Perpetual (undated for 30 patients each 
week); and Perpetual (undated for 60 patients each week). The 60- 
patient book consists of 256 pages of assorted blanks. The first three 
styles contain 32 pages of important data, thoroughly revised, and 
160 pages of assorted blanks. Each in one volume, price, $1.25. 
With thumb-letter index for quick use, 25 cents extra. Special rates 
to advance-paying subscribers to The Medical News or The 
American Journal of the Medical Sciences, or both. Seep. 32. 

WATSON (THOMAS). LECTURES ON THE PRINCIPLES AND 
PRACTICE OF PHYSIC. A new American from the fifth and 
enlarged English edition, with additions by H. Hartshorne, M. D. 
In two large 8vo. vols, of 1840 pp., with 190 cuts. Cloth, $9 ; leather, $11. 

WEST (CHARLES). LECTURES ON THE DISEASES PECULIAR 
TO WOMEN. Third American from the third English edition. In 
one octavo volume of 543 pages. Cloth, $3.75 ; leather, $4.75. 

ON SOME DISORDERS OF THE NERVOUS SYSTEM IN 

CHILDHOOD. In one small 12mo. volume of 127 pages. Cloth, $1. 



WHARTON (HENRY R.). MINOR SURGERY AND BANDAG- 
ING. New (3d) edition. In one 12mo. vol. of 594 pages, with 475 
engravings, many of which are photographic. Cloth, 



$3. 



We know of no book which more 
thoroughly or more satisfactorily 
covers the ground of Minor Surgery 
and Bandaging. — Brooklyn Medical 
Journal. 

Well written, conveniently ar- 
ranged and amply illustrated. It 
covers the field so fully as to render 
it a valuable text-book, as well as a 



work of ready reference for sur- 
geons. — North Amer. Practitioner. 
The part devoted to bandaging is 
perhaps the best exposition of the 
subject in the English language. It 
can be highly commended to the 
student, the practitioner and the 
specialist. — The Chicago Medical 
Recorder. 



Lea Brothers & Co., Philadelphia and New York. 31 

WHITLA (WILLIAM). DICTIONARY OF TREATMENT, OR 

THERAPEUTIC INDEX. Including Medical and Surgical Thera- 
peutics. In one square octavo volume of 917 pages. Cloth, $4. 

WILLIA3IS (DAWSON). THE MEDICAL DISEASES OF CHIL- 
DREN. In one 12mo. volume of 629 pages, with 18 illustrations. 
Just ready. Cloth, $2.50, net. 

WILSON (ERASMUS). A SYSTEM OF HUMAN ANATOMY. 

A new and revised American from the last English edition. Illustrated 
with 397 engravings. In one octavo volume of 616 pages. Cloth, $4 ; 
leather, $5. 

THE STUDENT'S BOOK OF CUTANEOUS MEDICINE. In 



one 12mo. volume. Cloth, $3.50. 

WINCKEL ON PATHOLOGY AND TREATMENT OF CHILDBED. 
Translated by James R. Chadwick, A. M., M. D. With additions 
by the Author. In one octavo volume of 484 pages. Cloth, $4. 

WOHLERS OUTLINES OF ORGANIC CHEMISTRY. Translated 
from the eighth German edition, by Ira Remsen, M. D. In one 
12mo. volume of 550 pages. Cloth, $3. 

YEAR-BOOK OF TREATMENT FOR 1899. A Critical Review for 
Practitioners of Medicine and Surgery. In contributions by 25 well- 
known medical writers. 12mo., 488 pages. Cloth, $1.50. In combi- 
nation with The Medical News and The American Journal 
of the Medical Sciences, 75 cents. 

To repeat the praises bestowed on \ the hands of a practical and recog- 

previous issues is not to do full jus- nized authority. The whole field of 

tice, as every year shows improve- medicine is in this way traversed, 

ment and advances which make the and a critical estimate formed of all 

work one of increasing utility to the that is substantial and meritorious 

physician. The work this year con- in recent progress. — The Physician 

sists of twenty-five chapters, each in and Surgeon. 

YEAR-BOOKS OF TREATMENT FOR 1892, 1893, 1896 and 1897, 
similar to above. Each, cloth, $1.50. 

YEO (I. BURNEY). FOOD IN HEALTH AND DISEASE. New 

(2d) edition. In one 12mo. volume of 592 pages, with 4 engravings. 
Cloth, $2.50. See Series of Clinical Manuals, page 26. 

We doubt whether any book on work of Dr. Yeo's. The value of 

dietetics has been of greater or more the work is not to be overestimated, 

widespread usefulness than has this — New York Medical Journal. 
much-quoted and much-consulted 



A MANUAL OF MEDICAL TREATMENT, OR CLINICAL 

THERAPEUTICS. Two volumes containing 1275 pages. Cloth, $5.50. 

YOUNG (JAMES K.). ORTHOPEDIC SURGERY. In one 8vo. 
volume of 475 pages, with 286 illustrations. Cloth, $4; leather, $5. 

In studying the different chapters, J surgical specialty and every page 
one is impressed with the thorough- j abounds with evidences of prac- 
ness of the work. The illustrations | ticality. It is the clearest and most 
are numerous — the book thoroughly I modern work upon this growing de- 
practical — Medical News. \ partment of surgery. — The Chicago 

It is a thorough, a very compre- ! Clinical Review. 
hensive work upon this legitimate 



PERIODICALS. 



PROGRESSIVE MEDICINE. 

A Quarterly Digest of New Methods, Discoveries, and Improvements 
in the Medical and Surgical Sciences by Eminent Authorities. Edited by 
Dr. Hobart Amory Hare. Iu four abundantly illustrated, cloth bound, 
octavo volumes, of 400-500 pages each, issued quarterly, commencing 
March 1st, 1899. Per annum (4 volumes), $10.00 delivered. 



THE MEDICAL. NEWS. 

Weekly, $4.00 per Annum. 

Each number contains 32 quarto pages, abundantly illustrated, 
crisp, fresh weekly professional newspaper. 



THE AMERICAN JOURNAL. OF THE MEDICAL SCIENCES. 
Monthly, $4.00 Per Annum. 

Each issue contains 128 octavo pages, fully illustrated. The most 
advanced and enterprising American exponent of scientific medicine. 



THE MEDICAL NEWS VISITING LIST FOR 1899. 

Four styles, Weekly (dated for 30 patients) ; Monthly (undated, for 
120 patients per month) ; Perpetual (undated, for 30 patients weekly per 
year) ; and Perpetual (undated, for 60 patients per year). Each style in 
one wallet-shaped book, leather bound, with pocket, pencil and rubber. 
Price, each, $1.25. Thumb-letter index, 25 cents extra. 



THE MEDICAL NEWS POCKET FORMULARY 
FOR 1899. 

Containing 1600 prescriptions representing the latest and most ap- 
proved methods of administering remedial agents. Strongly bound in 
leather ; with pocket and pencil. Price, $1.50, net. 



COMBINATION RATES: 



American Journal of the Alone. In Combination. 



5S Medical Sciences, 

z Medical News . 

< Progressive Medicine . 

« Medical News Visiting List 

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4.00} $ 7 - 50 t $15.00 

10.00 J 

1.35 
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In all S30.75 for »16.00 



First four above publications in combination . . JS15.75 
All above publications in combination .... 16.00 

Other Combinations will be quoted on request. 
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OCT -0 !9'i! 



